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The Healthy Brain Initiative A National Public Health Road Map to Maintaining Cognitive Health
TheHealthyBrainInitiative A National Public Health Road Map to Maintaining Cognitive Health
TableofContents
Acknowledgements
Executive Summary 1
I Background 4 Whatiscognitivehealth 5 WhyprepareaRoadMap 7 Whyisitimportantmdashandwhynow 12
II State of Knowledge 16 Whatdoweknow 17 Whatgapsexist 18 Howcanpublichealthcontribute 19
III Strategic Framework 22 Whatisourmodelforaction 23 Whatprinciplesdoweembrace 25 Whatdowehopetoaccomplish 26
IV Development Process 28 Workgroupdeliberations 29 Concept-mappingprocess 34
V Actions by Cluster 36 Disseminatinginformation 38 Translatingknowledge 40 Implementingpolicy 41 Conductingsurveillance 43 Movingresearchintopractice 44 Conductinginterventionresearch 47 Measuringcognitiveimpairment andburden 50 Developingcapacity 51
VI Next Steps 52 Prioritiesforaction 53 Implementation 57 Conclusion 57
Appendix A Contributors 58
Appendix B References 62
Suggested Citation CentersforDiseaseControlandPreventionandtheAlzheimerrsquos AssociationTheHealthyBrainInitiativeANationalPublicHealthRoadMapto MaintainingCognitiveHealthChicagoILAlzheimerrsquosAssociation2007
Availableatwwwcdcgovagingandwwwalzorg
Centers for Disease Control and Prevention and the Alzheimerrsquos Association
Acknowledgements
WethankthemembersoftheSteeringCommitteeforgivingcountlesshourstothink aboutanddiscussthisNational Public Health Road Map to Maintaining Cognitive Health theircontributionshavebeeninvaluable
LyndaAndersonPhD(Cochair) Centers for Disease Control and Prevention
StephenMcConnellPhD(Cochair) Alzheimerrsquos Association
FrankBaileyJD AARP
WilliamFBenson Health Benefits ABCrsquos
DebraCherryPhD Alzheimerrsquos Association
GregCase Administration on Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
JamesLaditkaDAPhDMPA University of South Carolina
DebraLappinJD BampD Consulting LLC
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
RamonaLRusinakRNPhD Arizona Department of Health Services
TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ExecutiveSummary
InFall2005theCentersforDiseaseControlandPrevention andtheAlzheimerrsquosAssociationformedanewpartnership
toexaminehowbesttobringapublichealthperspectiveto thepromotionofcognitivehealthToassistwiththisHealthy BrainInitiativethePartnersworkedcloselywiththeNational InstituteonAgingandtheAdministrationonAgingtoconvene amultidisciplinarySteeringCommitteeandanevenwider arrayofinvitedexpertsfromconcernedpublicandprivate sectororganizationsTogetherweexaminedthecurrentstate ofknowledgeregardingthepromotionandprotectionof cognitivehealthidentifiedimportantknowledgegapsand definedtheuniqueroleandcontributionsofpublichealth Wefocusedonvascularriskfactorsandphysicalactivity becauseoftheirassociationwithcognitiveoutcomesadopted astrategicframeworkandembarkedonanintensiveprocess togeneratetheactionsofferedinthis National Public Health Road Map to Maintaining Cognitive Health
TheRoadMaprecognizescurrentsocialtrendsandother factorsthataffectcognitivehealthfromapublichealth standpointanagingpopulationgrowingfearandconcern expressedbymanypeopleastheyageabouttheirpotential lossofcognitivefunctionincreasingsocietalburdenfrom cognitivedeclinegreatercaregiverburdenandacontinued lackofawarenessaboutcognitivehealthamongconsumers andprovidersalike
Withthisbackdropweofferaloftybutachievablelongshytermgoal
To maintain or improve the cognitive performance of all adults
Toaccomplishthisgoalweproposeasetof44actionsthat arefirmlygroundedinscienceemphasizeprimaryprevention assumeacommunityandpopulationapproachandare committedtoeliminatingdisparitiesinpersonalhealthand healthcareforracialorethnicgroupsItiscriticaltonotethat eachpriorityactionisbasedonadetailedscientificrationale withimplementationtobebasedondemonstratedeffectiveness ofspecificinterventionsTheseactionsshouldthereforebe consideredinthecontextoftherationalespresentedin SectionVoftheRoadMapWithinthefullsetofactionsare 10prioritiesworthyofimmediateattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ExecutiveSummary
bull Determinehowdiverseaudiencesthinkaboutcognitive healthanditsassociationswithlifestylefactors
bull Disseminatethelatestsciencetoincreasepublicunderstanding ofcognitivehealthandtodispelcommonmisconceptions
bull Helppeopleunderstandtheconnectionbetweenriskand protectivefactorsandcognitivehealth
bull Conductsystematicliteraturereviewsonproposedrisk factors(vascularriskandphysicalinactivity)andrelated interventionsforrelationshipswithcognitivehealthharms gapsandeffectiveness
bull Conductcontrolledclinicaltrialstodeterminetheeffect ofreducingvascularriskfactorsonloweringtheriskof cognitivedeclineandimprovingcognitivefunction
bull Conductcontrolledclinicaltrialstodeterminetheeffectof physicalactivityonreducingtheriskofcognitivedecline andimprovingcognitivefunction
bull Conductresearchonotherareaspotentiallyaffecting cognitivehealthsuchasnutritionmentalactivityand socialengagement
bull Developapopulation-basedsurveillancesystemwith longitudinalfollow-upthatisdedicatedtomeasuringthe publichealthburdenofcognitiveimpairmentinthe UnitedStates
bull Initiatepolicychangesatthefederalstateandlocallevels topromotecognitivehealthbyengagingpublicofficials
bull IncludecognitivehealthinHealthy People 2020aset ofhealthobjectivesforthenationthatwillserveasthe foundationforstateandcommunitypublichealthplans
Itisourhopethatthese10priorityactionswillservetofocus thenationrsquosresourcesonaddressingriskandprotectivefactors forpromotingcognitivehealthoverthenext3-5yearsAsa livingandflexibledocumenttheRoadMaprepresentsboth acalltoactionandaguideforimplementinganeffective coordinatedapproachtomovingcognitivehealthintopublic healthpracticeThekeytosuccessliesincontinuingand expandingresearchdevelopingandchannelingresources workingtodeveloporstrengthenpartnershipswithlikeshymindedorganizationsdesigningcollaborativeoperational plansofactionandestablishingsystemstotrackprogress facilitatecommunicationandexchangeinformation
Continuedvigilanceonthisissueandtimelytranslationof researchfindingsintocommunityactionwillassurethat wereapthepotentialrewardsthatpublichealthcanofferin improvingqualityoflifeamongadultsandreducingsocietal costsforhealthcareandotherservices
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
Background What is cognitive health
Thedistinctionbetweenthemindandbodywasaconcept firstformallysetforthinthe17thcenturybyphilosopher ReneDescartesOverthenextseveralcenturiesthebody wasseenastheconcernofphysicianswhilethemindwas thepurviewoforganizedreligion1
Overtheyearsourunderstandingofldquobodyandmindrdquo hasevolvedsignificantlyWenowrecognizethevitalrole thatbothphysicalhealthandmentalhealthplayinshaping ouroverallwell beingandweappreciatethevaluable contributionsthatawidearrayofhealthprofessionscan maketowardassuringthatwell-being
Background
Mentalhealthencompassesemotionalfunctioningandthe abilitytothinkreasonandremember(cognitivefunctioning) Whilestandardizedwidelyaccepteddefinitionsofcognitive healthhaveyettobeadoptedmostexpertsagreethatthe componentsofhealthycognitive functioning include
bull language bull thought bull memory bull executivefunction(theabilitytoplanandcarryouttasks) bull judgment bull attention bull perception bull rememberedskills(suchasdriving) bull abilitytoliveapurposefullife2
Muchlikephysicalhealthcognitivehealthcanbeviewed alongacontinuummdashfromoptimalfunctioningtomild cognitiveimpairmenttoseveredementiaItisnotsimplythe absenceofdiseasessuchasAlzheimerrsquosdiseaseratheritshould berespectedforitsmultidimensionalnatureandthechanges thattakeplaceoverthelifespanshouldbeacceptedeven embracedasanaturalpartoftheagingprocess3
Cognitivedeclinecanrangefrommildcognitiveimpairment todementiabutthesetwoconditionsarenotnecessarily manifestationsofthesamediseaseManypeoplenever developanyseriousdeclineintheircognitiveperformance andthosewhodevelopmildcognitiveproblemsdonot necessarilydevelopdementiaAlthoughnotallpeoplewith cognitivedeclinedevelopdementiathosewithanamnestic formofmildcognitiveimpairmentdohaveamuchhigher riskfordementiathanotheradults
Thelackofcognitivehealthcanhaveprofoundimplications forapersonrsquosphysicalhealthOlderadultsandothers experiencingcognitiveimpairmentmaybeunabletocare forthemselvesortoengageinnecessaryactivitiesofdaily livingsuchaspreparingmealsormanagingtheirfinances Limitationsintheabilitytoeffectivelymanagemedications andexistingmedicalconditionsareofparticularconcernwhen apersonisexperiencingcognitiveimpairmentordementia
Dementiaaffectsapersonrsquosabilitytocomprehendandacton messagesandinvolvesproblemswithmemoryunderstanding orusingwordsandidentifyingobjectsThesignificantly impairedcognitionassociatedwithdementialeadstoalossof senseofselfandoflifelongmemoriesadecreasingabilityto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoMostimportanttoourabilitytoliveourliveswellisthe combinationofmentalprocesseswecalllsquocognitionrsquoor lsquoknowingrsquoThiscombinationincludestheabilitytolearn newthingsintuitionjudgmentlanguageandremembering Havingaclearactivemindatanyageisimportantbutas wegetolderitcanmeanthedifferencebetweendependence andindependentlivingrdquo4
copewiththenormaldemandsoflivingproblemsaccessing healthcaresystemsgreatervulnerabilitytodiseaseinjury malnutritioncrimeandpossiblyabuseandeventuallyaloss ofindependenceThatlossofindependencebecomesaburden onfamiliesandsocietyastheindividualrequiresmoreintense careandofteninstitutionalizationInthelaterstagesthe cognitiveimpairmentassociatedwithdementiawillcreatetotal dependencyandAlzheimerrsquosdiseaseisnowrankedasthe 8th-leadingcauseofdeath5
Why prepare a Road Map
Bringingapublichealthperspectivetocognitivehealth requiresaninclusiveandstrategicapproachMuchimportant workhasalreadybeguninitiatedandsponsoredbyavariety oforganizationsandagenciesatnationalstateandlocallevels (seepages10-11forasamplingofcurrentefforts)
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
OneoftheselandmarkeffortstheNationalInstitutesofHealth (NIH)CognitiveandEmotionalHealthProject(CEHP) wasofficiallylaunchedin2001Selectedexpertsfromseveral universitiesandtheNIHcriticallyanalyzedthescientific literaturetoidentifypossibleriskandprotectivefactorsfor maintainingcognitiveandemotionalhealthinadults6In recognitionoftheimportanceofthiseffortandasfurther testamenttotheincreasedvisibilitythatcognitivehealthis receivingCongressappropriatedfundsinfiscalyear2005to theCentersforDiseaseControlandPrevention(CDC)to addresscognitivehealthwithafocusonlifestyleissuesWith thissupportCDCformedapartnershipwiththeAlzheimerrsquos AssociationandisworkingcloselywiththeNationalInstitute onAgingtheAdministrationonAgingandotherpublicand privatesectororganizationsonaHealthyBrainInitiative
Thispartnership
bull FormedaSteeringCommitteemadeupofnationalexperts toprovideoverallguidanceandcoordinationfortheInitiative (AppendixA)
bull ConvenedaPublicHealthResearchWorkingGroup MeetinginMay2006onThe Healthy Brain and Our Aging PopulationTranslating Science to Public Health PracticeDuring
this2-dayinvitationalmeetingnationalexpertsreviewed researchinpublichealthpreventionrelatedtobrainhealth anddiscussedspecificrecommendationsforaddressingrisk andprotectivefactorsforpromotingcognitivehealthThey focusedonvascularriskfactorsandphysicalactivitybecause oftheirassociationwithcognitiveoutcomes
Thefindingsfromthisresearchmeetingprovidedafoundation andcommonframeofreferenceforthenextstepoftheHealthy BrainInitiativedevelopingstrategicpublichealthrecommenshydationsForthistaskthePartnershipformedworkgroups infourareasofpublichealthactionPreventionResearch CommunicationSurveillanceandPolicyEachworkgroup waschargedwithdraftingrecommendationsformovingthe nationforwardoverthenext3-5yearstowardthelong-term goalofmaintainingandimprovingthecognitivefunctionof adultsKeystakeholdersatthenationalstateandlocallevels thenrefinedtherecommendationsandselectedthoseof highestpriority(AppendixA)
TheNational Public Health Road Map to Maintaining Cognitive Healthreflectstheculminationofthis18-monthprocessAsa cornerstoneoftheInitiativeitoffersapathforhowwecan learnmoreaboutcognitivehealthandthenultimately
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoWearebeginningtotakethe nextstepsbuildingonthe researchcomingoutofNIH andothersandmovingwhat weknowoutintocommunity practiceThisiswherewecan makeadifferenceinthe everydaylivesofAmericansrdquo LyndaAAndersonPhD Healthy Aging Program Centers for Disease Control and Prevention
translatewhatwelearnintoreal-worldpracticetoimprove thehealthofallAmericans
TheauthorsoftheRoadMaprecognizethatinthecourse ofdailylifethedomainsofemotionalandcognitivehealth areinextricablylinkedandcannottrulybeseparatedFor thisRoadMaphoweverweassumethisdistinctionandfocus solelyoncognitivehealthOnlyrecentlyhavepublichealth expertiseandresourcesbeenrecognizedforaddressing cognitivehealthTheRoadMapreflectsacommitmentto bringtheareaofcognitivehealthldquouptoparrdquowithemotional healthastreatmentsandpreventivestrategiesbecomeavailable Itisthefirststepinasystematicprocessforbringingcognitive andemotionalhealthtogetherinamorecomprehensiveand coordinatedpublichealthapproach
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
A Sampling of Current Efforts
Pursuing Research on Factors Influencing Cognitive Health
TheNationalInstitutesofHealth(NIH)isfundingongoing researchtoclarifytherelationshipamongminimizingvascular riskfactorsexerciseotherlifestyleanddruginterventions andcognitivehealthstatusEpidemiologicstudiesare identifyinglikelyriskandprotectivefactorsthesearebeing testedinanimalstudieswhichalsocanhelpidentifythe mechanismsbywhichriskandprotectivefactorsmightwork Inordertoconfirmthattheencouraginginterventions identifiedinepidemiologyandanimalstudiescouldactually maintaincognitivehealthifappliedtohumansclinicaltrials mustbecarriedoutSomearealreadyinprogressbutothers arestillonlyintheplanningphaseNIHkeepsthepublicupshyto-dateonthecurrentstateofthesciencethroughoperation ofaWebsiteandanationalclearinghouse
Assessing Public Perceptions
Formativeresearchwithdiversegroupsisrequiredtohelp gainunderstandingonthepublicrsquosperceptionsaboutcognitive healthOnesucheffortiscurrentlyunderwaywiththesupport ofCDCTheHealthyAgingResearchNetworkwithinits largerPreventionResearchCentersProgram(PRC-HAN) conductspreventionresearchonavarietyofhealthissues involvingolderadultsWithinthePRC-HANmembersare collaboratingonaseriesoffocusgroupsdesignedtoidentify howdiversegroupsofolderadultsunderstandcognitive healthandwhatapproachestohealthpromotionanddisease preventionrelatedtobrainhealththepublicmayfindmost appealingThisprojecthasrecentlybeenexpandedtoexamine theperceptionsofcaregiversandhealthcareprovidersItwill provideimportantdatathatcanbeaddedtowhatisalready knownaboutcognitiveorbrainhealthidentifygapsin knowledgeaboutcognitivehealthandrelatedriskfactors anddeterminewhethersuchbeliefsvaryacrossgeographical distancesandbetweendiversepopulationsFinallythisworkis designedtoleadtothedevelopmentandtestingofashortset ofquestionsthatcanbeusedtoassessthepublicrsquosandpossibly providersrsquoperceptionsaboutcognitivehealthforinclusionin ongoingnationalattitudinalsurveys
0 |TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting Community Education Programs
TheAlzheimerrsquosAssociationhasrecentlylauncheda5-year community-baseddemonstrationprojecttopromoteabrainshyhealthylifestyleThecommunityinterventionisdesignedto affectknowledgeandattitudesamongAfricanAmericanbaby boomersrelatedtophysicalactivityandvascularriskfactors anditwillbeoverlaidwithothergeneralhealthbehaviors suchasdietsocialactivityandmentalactivityDuringthefirst phaseofthisprojecttheAlzheimerrsquosAssociationisleadinga comprehensiveinterventionplanninganddevelopmenteffort includingformativeresearchtoassesscurrentneedsand obstaclesforthetargetpopulationelicitingcommunityinput andparticipationandcreatingacomprehensivemultilevel communityinterventionwithrobustevaluationmechanisms tomeasuretheeffectivenessofthepublichealthprogramin itsnextphase
Developing Common Measures of Cognitive Decline for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativeto developunifiedandintegratedmethodsandmeasuresof cognitiveemotionalmotorandsensoryhealthforusein largecohortstudiesandclinicaltrialsResearchershave expressedtheneedforbriefassessmenttoolsthatcouldbe usedasaformofldquocommoncurrencyrdquoacrossdiversestudy designsandpopulationsThisinitiativewilltakeadvantage ofstate-of-the-artpsychometricresearchandnoveltesting methodstodevelopaninnovativeapproachtoneurological andbehavioralhealthmeasurementUltimatelyitishoped thatthisapproachwillrespondtotheneedsofresearchersin avarietyofsettingswithparticularemphasisonmeasuring outcomesinlargelongitudinalandepidemiologicstudiesand preventionorinterventiontrialsacrossthelifespanWith anavailabletoolboxofmeasuresyieldsfromlargeandvery expensivestudiescanbemaximizedbyallowingamuch largernumberofimportantresearchquestionsregarding neurologicalandbehavioralhealthtobestudiedByensuring thattheassessmentmethodsarecapableofcomparisonto existingandcompletedstudiesandcanincorporatefuture modificationsatrulyldquoeconomicrdquoandvaluablenational resourcefortheentireneurosciencecommunitywillresult
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
Why is it importantmdashand why now
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline
An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10
Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia
bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12
bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
TheHealthyBrainInitiative A National Public Health Road Map to Maintaining Cognitive Health
TableofContents
Acknowledgements
Executive Summary 1
I Background 4 Whatiscognitivehealth 5 WhyprepareaRoadMap 7 Whyisitimportantmdashandwhynow 12
II State of Knowledge 16 Whatdoweknow 17 Whatgapsexist 18 Howcanpublichealthcontribute 19
III Strategic Framework 22 Whatisourmodelforaction 23 Whatprinciplesdoweembrace 25 Whatdowehopetoaccomplish 26
IV Development Process 28 Workgroupdeliberations 29 Concept-mappingprocess 34
V Actions by Cluster 36 Disseminatinginformation 38 Translatingknowledge 40 Implementingpolicy 41 Conductingsurveillance 43 Movingresearchintopractice 44 Conductinginterventionresearch 47 Measuringcognitiveimpairment andburden 50 Developingcapacity 51
VI Next Steps 52 Prioritiesforaction 53 Implementation 57 Conclusion 57
Appendix A Contributors 58
Appendix B References 62
Suggested Citation CentersforDiseaseControlandPreventionandtheAlzheimerrsquos AssociationTheHealthyBrainInitiativeANationalPublicHealthRoadMapto MaintainingCognitiveHealthChicagoILAlzheimerrsquosAssociation2007
Availableatwwwcdcgovagingandwwwalzorg
Centers for Disease Control and Prevention and the Alzheimerrsquos Association
Acknowledgements
WethankthemembersoftheSteeringCommitteeforgivingcountlesshourstothink aboutanddiscussthisNational Public Health Road Map to Maintaining Cognitive Health theircontributionshavebeeninvaluable
LyndaAndersonPhD(Cochair) Centers for Disease Control and Prevention
StephenMcConnellPhD(Cochair) Alzheimerrsquos Association
FrankBaileyJD AARP
WilliamFBenson Health Benefits ABCrsquos
DebraCherryPhD Alzheimerrsquos Association
GregCase Administration on Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
JamesLaditkaDAPhDMPA University of South Carolina
DebraLappinJD BampD Consulting LLC
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
RamonaLRusinakRNPhD Arizona Department of Health Services
TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ExecutiveSummary
InFall2005theCentersforDiseaseControlandPrevention andtheAlzheimerrsquosAssociationformedanewpartnership
toexaminehowbesttobringapublichealthperspectiveto thepromotionofcognitivehealthToassistwiththisHealthy BrainInitiativethePartnersworkedcloselywiththeNational InstituteonAgingandtheAdministrationonAgingtoconvene amultidisciplinarySteeringCommitteeandanevenwider arrayofinvitedexpertsfromconcernedpublicandprivate sectororganizationsTogetherweexaminedthecurrentstate ofknowledgeregardingthepromotionandprotectionof cognitivehealthidentifiedimportantknowledgegapsand definedtheuniqueroleandcontributionsofpublichealth Wefocusedonvascularriskfactorsandphysicalactivity becauseoftheirassociationwithcognitiveoutcomesadopted astrategicframeworkandembarkedonanintensiveprocess togeneratetheactionsofferedinthis National Public Health Road Map to Maintaining Cognitive Health
TheRoadMaprecognizescurrentsocialtrendsandother factorsthataffectcognitivehealthfromapublichealth standpointanagingpopulationgrowingfearandconcern expressedbymanypeopleastheyageabouttheirpotential lossofcognitivefunctionincreasingsocietalburdenfrom cognitivedeclinegreatercaregiverburdenandacontinued lackofawarenessaboutcognitivehealthamongconsumers andprovidersalike
Withthisbackdropweofferaloftybutachievablelongshytermgoal
To maintain or improve the cognitive performance of all adults
Toaccomplishthisgoalweproposeasetof44actionsthat arefirmlygroundedinscienceemphasizeprimaryprevention assumeacommunityandpopulationapproachandare committedtoeliminatingdisparitiesinpersonalhealthand healthcareforracialorethnicgroupsItiscriticaltonotethat eachpriorityactionisbasedonadetailedscientificrationale withimplementationtobebasedondemonstratedeffectiveness ofspecificinterventionsTheseactionsshouldthereforebe consideredinthecontextoftherationalespresentedin SectionVoftheRoadMapWithinthefullsetofactionsare 10prioritiesworthyofimmediateattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ExecutiveSummary
bull Determinehowdiverseaudiencesthinkaboutcognitive healthanditsassociationswithlifestylefactors
bull Disseminatethelatestsciencetoincreasepublicunderstanding ofcognitivehealthandtodispelcommonmisconceptions
bull Helppeopleunderstandtheconnectionbetweenriskand protectivefactorsandcognitivehealth
bull Conductsystematicliteraturereviewsonproposedrisk factors(vascularriskandphysicalinactivity)andrelated interventionsforrelationshipswithcognitivehealthharms gapsandeffectiveness
bull Conductcontrolledclinicaltrialstodeterminetheeffect ofreducingvascularriskfactorsonloweringtheriskof cognitivedeclineandimprovingcognitivefunction
bull Conductcontrolledclinicaltrialstodeterminetheeffectof physicalactivityonreducingtheriskofcognitivedecline andimprovingcognitivefunction
bull Conductresearchonotherareaspotentiallyaffecting cognitivehealthsuchasnutritionmentalactivityand socialengagement
bull Developapopulation-basedsurveillancesystemwith longitudinalfollow-upthatisdedicatedtomeasuringthe publichealthburdenofcognitiveimpairmentinthe UnitedStates
bull Initiatepolicychangesatthefederalstateandlocallevels topromotecognitivehealthbyengagingpublicofficials
bull IncludecognitivehealthinHealthy People 2020aset ofhealthobjectivesforthenationthatwillserveasthe foundationforstateandcommunitypublichealthplans
Itisourhopethatthese10priorityactionswillservetofocus thenationrsquosresourcesonaddressingriskandprotectivefactors forpromotingcognitivehealthoverthenext3-5yearsAsa livingandflexibledocumenttheRoadMaprepresentsboth acalltoactionandaguideforimplementinganeffective coordinatedapproachtomovingcognitivehealthintopublic healthpracticeThekeytosuccessliesincontinuingand expandingresearchdevelopingandchannelingresources workingtodeveloporstrengthenpartnershipswithlikeshymindedorganizationsdesigningcollaborativeoperational plansofactionandestablishingsystemstotrackprogress facilitatecommunicationandexchangeinformation
Continuedvigilanceonthisissueandtimelytranslationof researchfindingsintocommunityactionwillassurethat wereapthepotentialrewardsthatpublichealthcanofferin improvingqualityoflifeamongadultsandreducingsocietal costsforhealthcareandotherservices
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
Background What is cognitive health
Thedistinctionbetweenthemindandbodywasaconcept firstformallysetforthinthe17thcenturybyphilosopher ReneDescartesOverthenextseveralcenturiesthebody wasseenastheconcernofphysicianswhilethemindwas thepurviewoforganizedreligion1
Overtheyearsourunderstandingofldquobodyandmindrdquo hasevolvedsignificantlyWenowrecognizethevitalrole thatbothphysicalhealthandmentalhealthplayinshaping ouroverallwell beingandweappreciatethevaluable contributionsthatawidearrayofhealthprofessionscan maketowardassuringthatwell-being
Background
Mentalhealthencompassesemotionalfunctioningandthe abilitytothinkreasonandremember(cognitivefunctioning) Whilestandardizedwidelyaccepteddefinitionsofcognitive healthhaveyettobeadoptedmostexpertsagreethatthe componentsofhealthycognitive functioning include
bull language bull thought bull memory bull executivefunction(theabilitytoplanandcarryouttasks) bull judgment bull attention bull perception bull rememberedskills(suchasdriving) bull abilitytoliveapurposefullife2
Muchlikephysicalhealthcognitivehealthcanbeviewed alongacontinuummdashfromoptimalfunctioningtomild cognitiveimpairmenttoseveredementiaItisnotsimplythe absenceofdiseasessuchasAlzheimerrsquosdiseaseratheritshould berespectedforitsmultidimensionalnatureandthechanges thattakeplaceoverthelifespanshouldbeacceptedeven embracedasanaturalpartoftheagingprocess3
Cognitivedeclinecanrangefrommildcognitiveimpairment todementiabutthesetwoconditionsarenotnecessarily manifestationsofthesamediseaseManypeoplenever developanyseriousdeclineintheircognitiveperformance andthosewhodevelopmildcognitiveproblemsdonot necessarilydevelopdementiaAlthoughnotallpeoplewith cognitivedeclinedevelopdementiathosewithanamnestic formofmildcognitiveimpairmentdohaveamuchhigher riskfordementiathanotheradults
Thelackofcognitivehealthcanhaveprofoundimplications forapersonrsquosphysicalhealthOlderadultsandothers experiencingcognitiveimpairmentmaybeunabletocare forthemselvesortoengageinnecessaryactivitiesofdaily livingsuchaspreparingmealsormanagingtheirfinances Limitationsintheabilitytoeffectivelymanagemedications andexistingmedicalconditionsareofparticularconcernwhen apersonisexperiencingcognitiveimpairmentordementia
Dementiaaffectsapersonrsquosabilitytocomprehendandacton messagesandinvolvesproblemswithmemoryunderstanding orusingwordsandidentifyingobjectsThesignificantly impairedcognitionassociatedwithdementialeadstoalossof senseofselfandoflifelongmemoriesadecreasingabilityto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoMostimportanttoourabilitytoliveourliveswellisthe combinationofmentalprocesseswecalllsquocognitionrsquoor lsquoknowingrsquoThiscombinationincludestheabilitytolearn newthingsintuitionjudgmentlanguageandremembering Havingaclearactivemindatanyageisimportantbutas wegetolderitcanmeanthedifferencebetweendependence andindependentlivingrdquo4
copewiththenormaldemandsoflivingproblemsaccessing healthcaresystemsgreatervulnerabilitytodiseaseinjury malnutritioncrimeandpossiblyabuseandeventuallyaloss ofindependenceThatlossofindependencebecomesaburden onfamiliesandsocietyastheindividualrequiresmoreintense careandofteninstitutionalizationInthelaterstagesthe cognitiveimpairmentassociatedwithdementiawillcreatetotal dependencyandAlzheimerrsquosdiseaseisnowrankedasthe 8th-leadingcauseofdeath5
Why prepare a Road Map
Bringingapublichealthperspectivetocognitivehealth requiresaninclusiveandstrategicapproachMuchimportant workhasalreadybeguninitiatedandsponsoredbyavariety oforganizationsandagenciesatnationalstateandlocallevels (seepages10-11forasamplingofcurrentefforts)
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
OneoftheselandmarkeffortstheNationalInstitutesofHealth (NIH)CognitiveandEmotionalHealthProject(CEHP) wasofficiallylaunchedin2001Selectedexpertsfromseveral universitiesandtheNIHcriticallyanalyzedthescientific literaturetoidentifypossibleriskandprotectivefactorsfor maintainingcognitiveandemotionalhealthinadults6In recognitionoftheimportanceofthiseffortandasfurther testamenttotheincreasedvisibilitythatcognitivehealthis receivingCongressappropriatedfundsinfiscalyear2005to theCentersforDiseaseControlandPrevention(CDC)to addresscognitivehealthwithafocusonlifestyleissuesWith thissupportCDCformedapartnershipwiththeAlzheimerrsquos AssociationandisworkingcloselywiththeNationalInstitute onAgingtheAdministrationonAgingandotherpublicand privatesectororganizationsonaHealthyBrainInitiative
Thispartnership
bull FormedaSteeringCommitteemadeupofnationalexperts toprovideoverallguidanceandcoordinationfortheInitiative (AppendixA)
bull ConvenedaPublicHealthResearchWorkingGroup MeetinginMay2006onThe Healthy Brain and Our Aging PopulationTranslating Science to Public Health PracticeDuring
this2-dayinvitationalmeetingnationalexpertsreviewed researchinpublichealthpreventionrelatedtobrainhealth anddiscussedspecificrecommendationsforaddressingrisk andprotectivefactorsforpromotingcognitivehealthThey focusedonvascularriskfactorsandphysicalactivitybecause oftheirassociationwithcognitiveoutcomes
Thefindingsfromthisresearchmeetingprovidedafoundation andcommonframeofreferenceforthenextstepoftheHealthy BrainInitiativedevelopingstrategicpublichealthrecommenshydationsForthistaskthePartnershipformedworkgroups infourareasofpublichealthactionPreventionResearch CommunicationSurveillanceandPolicyEachworkgroup waschargedwithdraftingrecommendationsformovingthe nationforwardoverthenext3-5yearstowardthelong-term goalofmaintainingandimprovingthecognitivefunctionof adultsKeystakeholdersatthenationalstateandlocallevels thenrefinedtherecommendationsandselectedthoseof highestpriority(AppendixA)
TheNational Public Health Road Map to Maintaining Cognitive Healthreflectstheculminationofthis18-monthprocessAsa cornerstoneoftheInitiativeitoffersapathforhowwecan learnmoreaboutcognitivehealthandthenultimately
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoWearebeginningtotakethe nextstepsbuildingonthe researchcomingoutofNIH andothersandmovingwhat weknowoutintocommunity practiceThisiswherewecan makeadifferenceinthe everydaylivesofAmericansrdquo LyndaAAndersonPhD Healthy Aging Program Centers for Disease Control and Prevention
translatewhatwelearnintoreal-worldpracticetoimprove thehealthofallAmericans
TheauthorsoftheRoadMaprecognizethatinthecourse ofdailylifethedomainsofemotionalandcognitivehealth areinextricablylinkedandcannottrulybeseparatedFor thisRoadMaphoweverweassumethisdistinctionandfocus solelyoncognitivehealthOnlyrecentlyhavepublichealth expertiseandresourcesbeenrecognizedforaddressing cognitivehealthTheRoadMapreflectsacommitmentto bringtheareaofcognitivehealthldquouptoparrdquowithemotional healthastreatmentsandpreventivestrategiesbecomeavailable Itisthefirststepinasystematicprocessforbringingcognitive andemotionalhealthtogetherinamorecomprehensiveand coordinatedpublichealthapproach
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
A Sampling of Current Efforts
Pursuing Research on Factors Influencing Cognitive Health
TheNationalInstitutesofHealth(NIH)isfundingongoing researchtoclarifytherelationshipamongminimizingvascular riskfactorsexerciseotherlifestyleanddruginterventions andcognitivehealthstatusEpidemiologicstudiesare identifyinglikelyriskandprotectivefactorsthesearebeing testedinanimalstudieswhichalsocanhelpidentifythe mechanismsbywhichriskandprotectivefactorsmightwork Inordertoconfirmthattheencouraginginterventions identifiedinepidemiologyandanimalstudiescouldactually maintaincognitivehealthifappliedtohumansclinicaltrials mustbecarriedoutSomearealreadyinprogressbutothers arestillonlyintheplanningphaseNIHkeepsthepublicupshyto-dateonthecurrentstateofthesciencethroughoperation ofaWebsiteandanationalclearinghouse
Assessing Public Perceptions
Formativeresearchwithdiversegroupsisrequiredtohelp gainunderstandingonthepublicrsquosperceptionsaboutcognitive healthOnesucheffortiscurrentlyunderwaywiththesupport ofCDCTheHealthyAgingResearchNetworkwithinits largerPreventionResearchCentersProgram(PRC-HAN) conductspreventionresearchonavarietyofhealthissues involvingolderadultsWithinthePRC-HANmembersare collaboratingonaseriesoffocusgroupsdesignedtoidentify howdiversegroupsofolderadultsunderstandcognitive healthandwhatapproachestohealthpromotionanddisease preventionrelatedtobrainhealththepublicmayfindmost appealingThisprojecthasrecentlybeenexpandedtoexamine theperceptionsofcaregiversandhealthcareprovidersItwill provideimportantdatathatcanbeaddedtowhatisalready knownaboutcognitiveorbrainhealthidentifygapsin knowledgeaboutcognitivehealthandrelatedriskfactors anddeterminewhethersuchbeliefsvaryacrossgeographical distancesandbetweendiversepopulationsFinallythisworkis designedtoleadtothedevelopmentandtestingofashortset ofquestionsthatcanbeusedtoassessthepublicrsquosandpossibly providersrsquoperceptionsaboutcognitivehealthforinclusionin ongoingnationalattitudinalsurveys
0 |TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting Community Education Programs
TheAlzheimerrsquosAssociationhasrecentlylauncheda5-year community-baseddemonstrationprojecttopromoteabrainshyhealthylifestyleThecommunityinterventionisdesignedto affectknowledgeandattitudesamongAfricanAmericanbaby boomersrelatedtophysicalactivityandvascularriskfactors anditwillbeoverlaidwithothergeneralhealthbehaviors suchasdietsocialactivityandmentalactivityDuringthefirst phaseofthisprojecttheAlzheimerrsquosAssociationisleadinga comprehensiveinterventionplanninganddevelopmenteffort includingformativeresearchtoassesscurrentneedsand obstaclesforthetargetpopulationelicitingcommunityinput andparticipationandcreatingacomprehensivemultilevel communityinterventionwithrobustevaluationmechanisms tomeasuretheeffectivenessofthepublichealthprogramin itsnextphase
Developing Common Measures of Cognitive Decline for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativeto developunifiedandintegratedmethodsandmeasuresof cognitiveemotionalmotorandsensoryhealthforusein largecohortstudiesandclinicaltrialsResearchershave expressedtheneedforbriefassessmenttoolsthatcouldbe usedasaformofldquocommoncurrencyrdquoacrossdiversestudy designsandpopulationsThisinitiativewilltakeadvantage ofstate-of-the-artpsychometricresearchandnoveltesting methodstodevelopaninnovativeapproachtoneurological andbehavioralhealthmeasurementUltimatelyitishoped thatthisapproachwillrespondtotheneedsofresearchersin avarietyofsettingswithparticularemphasisonmeasuring outcomesinlargelongitudinalandepidemiologicstudiesand preventionorinterventiontrialsacrossthelifespanWith anavailabletoolboxofmeasuresyieldsfromlargeandvery expensivestudiescanbemaximizedbyallowingamuch largernumberofimportantresearchquestionsregarding neurologicalandbehavioralhealthtobestudiedByensuring thattheassessmentmethodsarecapableofcomparisonto existingandcompletedstudiesandcanincorporatefuture modificationsatrulyldquoeconomicrdquoandvaluablenational resourcefortheentireneurosciencecommunitywillresult
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
Why is it importantmdashand why now
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline
An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10
Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia
bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12
bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Acknowledgements
WethankthemembersoftheSteeringCommitteeforgivingcountlesshourstothink aboutanddiscussthisNational Public Health Road Map to Maintaining Cognitive Health theircontributionshavebeeninvaluable
LyndaAndersonPhD(Cochair) Centers for Disease Control and Prevention
StephenMcConnellPhD(Cochair) Alzheimerrsquos Association
FrankBaileyJD AARP
WilliamFBenson Health Benefits ABCrsquos
DebraCherryPhD Alzheimerrsquos Association
GregCase Administration on Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
JamesLaditkaDAPhDMPA University of South Carolina
DebraLappinJD BampD Consulting LLC
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
RamonaLRusinakRNPhD Arizona Department of Health Services
TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ExecutiveSummary
InFall2005theCentersforDiseaseControlandPrevention andtheAlzheimerrsquosAssociationformedanewpartnership
toexaminehowbesttobringapublichealthperspectiveto thepromotionofcognitivehealthToassistwiththisHealthy BrainInitiativethePartnersworkedcloselywiththeNational InstituteonAgingandtheAdministrationonAgingtoconvene amultidisciplinarySteeringCommitteeandanevenwider arrayofinvitedexpertsfromconcernedpublicandprivate sectororganizationsTogetherweexaminedthecurrentstate ofknowledgeregardingthepromotionandprotectionof cognitivehealthidentifiedimportantknowledgegapsand definedtheuniqueroleandcontributionsofpublichealth Wefocusedonvascularriskfactorsandphysicalactivity becauseoftheirassociationwithcognitiveoutcomesadopted astrategicframeworkandembarkedonanintensiveprocess togeneratetheactionsofferedinthis National Public Health Road Map to Maintaining Cognitive Health
TheRoadMaprecognizescurrentsocialtrendsandother factorsthataffectcognitivehealthfromapublichealth standpointanagingpopulationgrowingfearandconcern expressedbymanypeopleastheyageabouttheirpotential lossofcognitivefunctionincreasingsocietalburdenfrom cognitivedeclinegreatercaregiverburdenandacontinued lackofawarenessaboutcognitivehealthamongconsumers andprovidersalike
Withthisbackdropweofferaloftybutachievablelongshytermgoal
To maintain or improve the cognitive performance of all adults
Toaccomplishthisgoalweproposeasetof44actionsthat arefirmlygroundedinscienceemphasizeprimaryprevention assumeacommunityandpopulationapproachandare committedtoeliminatingdisparitiesinpersonalhealthand healthcareforracialorethnicgroupsItiscriticaltonotethat eachpriorityactionisbasedonadetailedscientificrationale withimplementationtobebasedondemonstratedeffectiveness ofspecificinterventionsTheseactionsshouldthereforebe consideredinthecontextoftherationalespresentedin SectionVoftheRoadMapWithinthefullsetofactionsare 10prioritiesworthyofimmediateattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ExecutiveSummary
bull Determinehowdiverseaudiencesthinkaboutcognitive healthanditsassociationswithlifestylefactors
bull Disseminatethelatestsciencetoincreasepublicunderstanding ofcognitivehealthandtodispelcommonmisconceptions
bull Helppeopleunderstandtheconnectionbetweenriskand protectivefactorsandcognitivehealth
bull Conductsystematicliteraturereviewsonproposedrisk factors(vascularriskandphysicalinactivity)andrelated interventionsforrelationshipswithcognitivehealthharms gapsandeffectiveness
bull Conductcontrolledclinicaltrialstodeterminetheeffect ofreducingvascularriskfactorsonloweringtheriskof cognitivedeclineandimprovingcognitivefunction
bull Conductcontrolledclinicaltrialstodeterminetheeffectof physicalactivityonreducingtheriskofcognitivedecline andimprovingcognitivefunction
bull Conductresearchonotherareaspotentiallyaffecting cognitivehealthsuchasnutritionmentalactivityand socialengagement
bull Developapopulation-basedsurveillancesystemwith longitudinalfollow-upthatisdedicatedtomeasuringthe publichealthburdenofcognitiveimpairmentinthe UnitedStates
bull Initiatepolicychangesatthefederalstateandlocallevels topromotecognitivehealthbyengagingpublicofficials
bull IncludecognitivehealthinHealthy People 2020aset ofhealthobjectivesforthenationthatwillserveasthe foundationforstateandcommunitypublichealthplans
Itisourhopethatthese10priorityactionswillservetofocus thenationrsquosresourcesonaddressingriskandprotectivefactors forpromotingcognitivehealthoverthenext3-5yearsAsa livingandflexibledocumenttheRoadMaprepresentsboth acalltoactionandaguideforimplementinganeffective coordinatedapproachtomovingcognitivehealthintopublic healthpracticeThekeytosuccessliesincontinuingand expandingresearchdevelopingandchannelingresources workingtodeveloporstrengthenpartnershipswithlikeshymindedorganizationsdesigningcollaborativeoperational plansofactionandestablishingsystemstotrackprogress facilitatecommunicationandexchangeinformation
Continuedvigilanceonthisissueandtimelytranslationof researchfindingsintocommunityactionwillassurethat wereapthepotentialrewardsthatpublichealthcanofferin improvingqualityoflifeamongadultsandreducingsocietal costsforhealthcareandotherservices
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
Background What is cognitive health
Thedistinctionbetweenthemindandbodywasaconcept firstformallysetforthinthe17thcenturybyphilosopher ReneDescartesOverthenextseveralcenturiesthebody wasseenastheconcernofphysicianswhilethemindwas thepurviewoforganizedreligion1
Overtheyearsourunderstandingofldquobodyandmindrdquo hasevolvedsignificantlyWenowrecognizethevitalrole thatbothphysicalhealthandmentalhealthplayinshaping ouroverallwell beingandweappreciatethevaluable contributionsthatawidearrayofhealthprofessionscan maketowardassuringthatwell-being
Background
Mentalhealthencompassesemotionalfunctioningandthe abilitytothinkreasonandremember(cognitivefunctioning) Whilestandardizedwidelyaccepteddefinitionsofcognitive healthhaveyettobeadoptedmostexpertsagreethatthe componentsofhealthycognitive functioning include
bull language bull thought bull memory bull executivefunction(theabilitytoplanandcarryouttasks) bull judgment bull attention bull perception bull rememberedskills(suchasdriving) bull abilitytoliveapurposefullife2
Muchlikephysicalhealthcognitivehealthcanbeviewed alongacontinuummdashfromoptimalfunctioningtomild cognitiveimpairmenttoseveredementiaItisnotsimplythe absenceofdiseasessuchasAlzheimerrsquosdiseaseratheritshould berespectedforitsmultidimensionalnatureandthechanges thattakeplaceoverthelifespanshouldbeacceptedeven embracedasanaturalpartoftheagingprocess3
Cognitivedeclinecanrangefrommildcognitiveimpairment todementiabutthesetwoconditionsarenotnecessarily manifestationsofthesamediseaseManypeoplenever developanyseriousdeclineintheircognitiveperformance andthosewhodevelopmildcognitiveproblemsdonot necessarilydevelopdementiaAlthoughnotallpeoplewith cognitivedeclinedevelopdementiathosewithanamnestic formofmildcognitiveimpairmentdohaveamuchhigher riskfordementiathanotheradults
Thelackofcognitivehealthcanhaveprofoundimplications forapersonrsquosphysicalhealthOlderadultsandothers experiencingcognitiveimpairmentmaybeunabletocare forthemselvesortoengageinnecessaryactivitiesofdaily livingsuchaspreparingmealsormanagingtheirfinances Limitationsintheabilitytoeffectivelymanagemedications andexistingmedicalconditionsareofparticularconcernwhen apersonisexperiencingcognitiveimpairmentordementia
Dementiaaffectsapersonrsquosabilitytocomprehendandacton messagesandinvolvesproblemswithmemoryunderstanding orusingwordsandidentifyingobjectsThesignificantly impairedcognitionassociatedwithdementialeadstoalossof senseofselfandoflifelongmemoriesadecreasingabilityto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoMostimportanttoourabilitytoliveourliveswellisthe combinationofmentalprocesseswecalllsquocognitionrsquoor lsquoknowingrsquoThiscombinationincludestheabilitytolearn newthingsintuitionjudgmentlanguageandremembering Havingaclearactivemindatanyageisimportantbutas wegetolderitcanmeanthedifferencebetweendependence andindependentlivingrdquo4
copewiththenormaldemandsoflivingproblemsaccessing healthcaresystemsgreatervulnerabilitytodiseaseinjury malnutritioncrimeandpossiblyabuseandeventuallyaloss ofindependenceThatlossofindependencebecomesaburden onfamiliesandsocietyastheindividualrequiresmoreintense careandofteninstitutionalizationInthelaterstagesthe cognitiveimpairmentassociatedwithdementiawillcreatetotal dependencyandAlzheimerrsquosdiseaseisnowrankedasthe 8th-leadingcauseofdeath5
Why prepare a Road Map
Bringingapublichealthperspectivetocognitivehealth requiresaninclusiveandstrategicapproachMuchimportant workhasalreadybeguninitiatedandsponsoredbyavariety oforganizationsandagenciesatnationalstateandlocallevels (seepages10-11forasamplingofcurrentefforts)
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
OneoftheselandmarkeffortstheNationalInstitutesofHealth (NIH)CognitiveandEmotionalHealthProject(CEHP) wasofficiallylaunchedin2001Selectedexpertsfromseveral universitiesandtheNIHcriticallyanalyzedthescientific literaturetoidentifypossibleriskandprotectivefactorsfor maintainingcognitiveandemotionalhealthinadults6In recognitionoftheimportanceofthiseffortandasfurther testamenttotheincreasedvisibilitythatcognitivehealthis receivingCongressappropriatedfundsinfiscalyear2005to theCentersforDiseaseControlandPrevention(CDC)to addresscognitivehealthwithafocusonlifestyleissuesWith thissupportCDCformedapartnershipwiththeAlzheimerrsquos AssociationandisworkingcloselywiththeNationalInstitute onAgingtheAdministrationonAgingandotherpublicand privatesectororganizationsonaHealthyBrainInitiative
Thispartnership
bull FormedaSteeringCommitteemadeupofnationalexperts toprovideoverallguidanceandcoordinationfortheInitiative (AppendixA)
bull ConvenedaPublicHealthResearchWorkingGroup MeetinginMay2006onThe Healthy Brain and Our Aging PopulationTranslating Science to Public Health PracticeDuring
this2-dayinvitationalmeetingnationalexpertsreviewed researchinpublichealthpreventionrelatedtobrainhealth anddiscussedspecificrecommendationsforaddressingrisk andprotectivefactorsforpromotingcognitivehealthThey focusedonvascularriskfactorsandphysicalactivitybecause oftheirassociationwithcognitiveoutcomes
Thefindingsfromthisresearchmeetingprovidedafoundation andcommonframeofreferenceforthenextstepoftheHealthy BrainInitiativedevelopingstrategicpublichealthrecommenshydationsForthistaskthePartnershipformedworkgroups infourareasofpublichealthactionPreventionResearch CommunicationSurveillanceandPolicyEachworkgroup waschargedwithdraftingrecommendationsformovingthe nationforwardoverthenext3-5yearstowardthelong-term goalofmaintainingandimprovingthecognitivefunctionof adultsKeystakeholdersatthenationalstateandlocallevels thenrefinedtherecommendationsandselectedthoseof highestpriority(AppendixA)
TheNational Public Health Road Map to Maintaining Cognitive Healthreflectstheculminationofthis18-monthprocessAsa cornerstoneoftheInitiativeitoffersapathforhowwecan learnmoreaboutcognitivehealthandthenultimately
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoWearebeginningtotakethe nextstepsbuildingonthe researchcomingoutofNIH andothersandmovingwhat weknowoutintocommunity practiceThisiswherewecan makeadifferenceinthe everydaylivesofAmericansrdquo LyndaAAndersonPhD Healthy Aging Program Centers for Disease Control and Prevention
translatewhatwelearnintoreal-worldpracticetoimprove thehealthofallAmericans
TheauthorsoftheRoadMaprecognizethatinthecourse ofdailylifethedomainsofemotionalandcognitivehealth areinextricablylinkedandcannottrulybeseparatedFor thisRoadMaphoweverweassumethisdistinctionandfocus solelyoncognitivehealthOnlyrecentlyhavepublichealth expertiseandresourcesbeenrecognizedforaddressing cognitivehealthTheRoadMapreflectsacommitmentto bringtheareaofcognitivehealthldquouptoparrdquowithemotional healthastreatmentsandpreventivestrategiesbecomeavailable Itisthefirststepinasystematicprocessforbringingcognitive andemotionalhealthtogetherinamorecomprehensiveand coordinatedpublichealthapproach
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
A Sampling of Current Efforts
Pursuing Research on Factors Influencing Cognitive Health
TheNationalInstitutesofHealth(NIH)isfundingongoing researchtoclarifytherelationshipamongminimizingvascular riskfactorsexerciseotherlifestyleanddruginterventions andcognitivehealthstatusEpidemiologicstudiesare identifyinglikelyriskandprotectivefactorsthesearebeing testedinanimalstudieswhichalsocanhelpidentifythe mechanismsbywhichriskandprotectivefactorsmightwork Inordertoconfirmthattheencouraginginterventions identifiedinepidemiologyandanimalstudiescouldactually maintaincognitivehealthifappliedtohumansclinicaltrials mustbecarriedoutSomearealreadyinprogressbutothers arestillonlyintheplanningphaseNIHkeepsthepublicupshyto-dateonthecurrentstateofthesciencethroughoperation ofaWebsiteandanationalclearinghouse
Assessing Public Perceptions
Formativeresearchwithdiversegroupsisrequiredtohelp gainunderstandingonthepublicrsquosperceptionsaboutcognitive healthOnesucheffortiscurrentlyunderwaywiththesupport ofCDCTheHealthyAgingResearchNetworkwithinits largerPreventionResearchCentersProgram(PRC-HAN) conductspreventionresearchonavarietyofhealthissues involvingolderadultsWithinthePRC-HANmembersare collaboratingonaseriesoffocusgroupsdesignedtoidentify howdiversegroupsofolderadultsunderstandcognitive healthandwhatapproachestohealthpromotionanddisease preventionrelatedtobrainhealththepublicmayfindmost appealingThisprojecthasrecentlybeenexpandedtoexamine theperceptionsofcaregiversandhealthcareprovidersItwill provideimportantdatathatcanbeaddedtowhatisalready knownaboutcognitiveorbrainhealthidentifygapsin knowledgeaboutcognitivehealthandrelatedriskfactors anddeterminewhethersuchbeliefsvaryacrossgeographical distancesandbetweendiversepopulationsFinallythisworkis designedtoleadtothedevelopmentandtestingofashortset ofquestionsthatcanbeusedtoassessthepublicrsquosandpossibly providersrsquoperceptionsaboutcognitivehealthforinclusionin ongoingnationalattitudinalsurveys
0 |TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting Community Education Programs
TheAlzheimerrsquosAssociationhasrecentlylauncheda5-year community-baseddemonstrationprojecttopromoteabrainshyhealthylifestyleThecommunityinterventionisdesignedto affectknowledgeandattitudesamongAfricanAmericanbaby boomersrelatedtophysicalactivityandvascularriskfactors anditwillbeoverlaidwithothergeneralhealthbehaviors suchasdietsocialactivityandmentalactivityDuringthefirst phaseofthisprojecttheAlzheimerrsquosAssociationisleadinga comprehensiveinterventionplanninganddevelopmenteffort includingformativeresearchtoassesscurrentneedsand obstaclesforthetargetpopulationelicitingcommunityinput andparticipationandcreatingacomprehensivemultilevel communityinterventionwithrobustevaluationmechanisms tomeasuretheeffectivenessofthepublichealthprogramin itsnextphase
Developing Common Measures of Cognitive Decline for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativeto developunifiedandintegratedmethodsandmeasuresof cognitiveemotionalmotorandsensoryhealthforusein largecohortstudiesandclinicaltrialsResearchershave expressedtheneedforbriefassessmenttoolsthatcouldbe usedasaformofldquocommoncurrencyrdquoacrossdiversestudy designsandpopulationsThisinitiativewilltakeadvantage ofstate-of-the-artpsychometricresearchandnoveltesting methodstodevelopaninnovativeapproachtoneurological andbehavioralhealthmeasurementUltimatelyitishoped thatthisapproachwillrespondtotheneedsofresearchersin avarietyofsettingswithparticularemphasisonmeasuring outcomesinlargelongitudinalandepidemiologicstudiesand preventionorinterventiontrialsacrossthelifespanWith anavailabletoolboxofmeasuresyieldsfromlargeandvery expensivestudiescanbemaximizedbyallowingamuch largernumberofimportantresearchquestionsregarding neurologicalandbehavioralhealthtobestudiedByensuring thattheassessmentmethodsarecapableofcomparisonto existingandcompletedstudiesandcanincorporatefuture modificationsatrulyldquoeconomicrdquoandvaluablenational resourcefortheentireneurosciencecommunitywillresult
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
Why is it importantmdashand why now
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline
An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10
Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia
bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12
bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ExecutiveSummary
InFall2005theCentersforDiseaseControlandPrevention andtheAlzheimerrsquosAssociationformedanewpartnership
toexaminehowbesttobringapublichealthperspectiveto thepromotionofcognitivehealthToassistwiththisHealthy BrainInitiativethePartnersworkedcloselywiththeNational InstituteonAgingandtheAdministrationonAgingtoconvene amultidisciplinarySteeringCommitteeandanevenwider arrayofinvitedexpertsfromconcernedpublicandprivate sectororganizationsTogetherweexaminedthecurrentstate ofknowledgeregardingthepromotionandprotectionof cognitivehealthidentifiedimportantknowledgegapsand definedtheuniqueroleandcontributionsofpublichealth Wefocusedonvascularriskfactorsandphysicalactivity becauseoftheirassociationwithcognitiveoutcomesadopted astrategicframeworkandembarkedonanintensiveprocess togeneratetheactionsofferedinthis National Public Health Road Map to Maintaining Cognitive Health
TheRoadMaprecognizescurrentsocialtrendsandother factorsthataffectcognitivehealthfromapublichealth standpointanagingpopulationgrowingfearandconcern expressedbymanypeopleastheyageabouttheirpotential lossofcognitivefunctionincreasingsocietalburdenfrom cognitivedeclinegreatercaregiverburdenandacontinued lackofawarenessaboutcognitivehealthamongconsumers andprovidersalike
Withthisbackdropweofferaloftybutachievablelongshytermgoal
To maintain or improve the cognitive performance of all adults
Toaccomplishthisgoalweproposeasetof44actionsthat arefirmlygroundedinscienceemphasizeprimaryprevention assumeacommunityandpopulationapproachandare committedtoeliminatingdisparitiesinpersonalhealthand healthcareforracialorethnicgroupsItiscriticaltonotethat eachpriorityactionisbasedonadetailedscientificrationale withimplementationtobebasedondemonstratedeffectiveness ofspecificinterventionsTheseactionsshouldthereforebe consideredinthecontextoftherationalespresentedin SectionVoftheRoadMapWithinthefullsetofactionsare 10prioritiesworthyofimmediateattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ExecutiveSummary
bull Determinehowdiverseaudiencesthinkaboutcognitive healthanditsassociationswithlifestylefactors
bull Disseminatethelatestsciencetoincreasepublicunderstanding ofcognitivehealthandtodispelcommonmisconceptions
bull Helppeopleunderstandtheconnectionbetweenriskand protectivefactorsandcognitivehealth
bull Conductsystematicliteraturereviewsonproposedrisk factors(vascularriskandphysicalinactivity)andrelated interventionsforrelationshipswithcognitivehealthharms gapsandeffectiveness
bull Conductcontrolledclinicaltrialstodeterminetheeffect ofreducingvascularriskfactorsonloweringtheriskof cognitivedeclineandimprovingcognitivefunction
bull Conductcontrolledclinicaltrialstodeterminetheeffectof physicalactivityonreducingtheriskofcognitivedecline andimprovingcognitivefunction
bull Conductresearchonotherareaspotentiallyaffecting cognitivehealthsuchasnutritionmentalactivityand socialengagement
bull Developapopulation-basedsurveillancesystemwith longitudinalfollow-upthatisdedicatedtomeasuringthe publichealthburdenofcognitiveimpairmentinthe UnitedStates
bull Initiatepolicychangesatthefederalstateandlocallevels topromotecognitivehealthbyengagingpublicofficials
bull IncludecognitivehealthinHealthy People 2020aset ofhealthobjectivesforthenationthatwillserveasthe foundationforstateandcommunitypublichealthplans
Itisourhopethatthese10priorityactionswillservetofocus thenationrsquosresourcesonaddressingriskandprotectivefactors forpromotingcognitivehealthoverthenext3-5yearsAsa livingandflexibledocumenttheRoadMaprepresentsboth acalltoactionandaguideforimplementinganeffective coordinatedapproachtomovingcognitivehealthintopublic healthpracticeThekeytosuccessliesincontinuingand expandingresearchdevelopingandchannelingresources workingtodeveloporstrengthenpartnershipswithlikeshymindedorganizationsdesigningcollaborativeoperational plansofactionandestablishingsystemstotrackprogress facilitatecommunicationandexchangeinformation
Continuedvigilanceonthisissueandtimelytranslationof researchfindingsintocommunityactionwillassurethat wereapthepotentialrewardsthatpublichealthcanofferin improvingqualityoflifeamongadultsandreducingsocietal costsforhealthcareandotherservices
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
Background What is cognitive health
Thedistinctionbetweenthemindandbodywasaconcept firstformallysetforthinthe17thcenturybyphilosopher ReneDescartesOverthenextseveralcenturiesthebody wasseenastheconcernofphysicianswhilethemindwas thepurviewoforganizedreligion1
Overtheyearsourunderstandingofldquobodyandmindrdquo hasevolvedsignificantlyWenowrecognizethevitalrole thatbothphysicalhealthandmentalhealthplayinshaping ouroverallwell beingandweappreciatethevaluable contributionsthatawidearrayofhealthprofessionscan maketowardassuringthatwell-being
Background
Mentalhealthencompassesemotionalfunctioningandthe abilitytothinkreasonandremember(cognitivefunctioning) Whilestandardizedwidelyaccepteddefinitionsofcognitive healthhaveyettobeadoptedmostexpertsagreethatthe componentsofhealthycognitive functioning include
bull language bull thought bull memory bull executivefunction(theabilitytoplanandcarryouttasks) bull judgment bull attention bull perception bull rememberedskills(suchasdriving) bull abilitytoliveapurposefullife2
Muchlikephysicalhealthcognitivehealthcanbeviewed alongacontinuummdashfromoptimalfunctioningtomild cognitiveimpairmenttoseveredementiaItisnotsimplythe absenceofdiseasessuchasAlzheimerrsquosdiseaseratheritshould berespectedforitsmultidimensionalnatureandthechanges thattakeplaceoverthelifespanshouldbeacceptedeven embracedasanaturalpartoftheagingprocess3
Cognitivedeclinecanrangefrommildcognitiveimpairment todementiabutthesetwoconditionsarenotnecessarily manifestationsofthesamediseaseManypeoplenever developanyseriousdeclineintheircognitiveperformance andthosewhodevelopmildcognitiveproblemsdonot necessarilydevelopdementiaAlthoughnotallpeoplewith cognitivedeclinedevelopdementiathosewithanamnestic formofmildcognitiveimpairmentdohaveamuchhigher riskfordementiathanotheradults
Thelackofcognitivehealthcanhaveprofoundimplications forapersonrsquosphysicalhealthOlderadultsandothers experiencingcognitiveimpairmentmaybeunabletocare forthemselvesortoengageinnecessaryactivitiesofdaily livingsuchaspreparingmealsormanagingtheirfinances Limitationsintheabilitytoeffectivelymanagemedications andexistingmedicalconditionsareofparticularconcernwhen apersonisexperiencingcognitiveimpairmentordementia
Dementiaaffectsapersonrsquosabilitytocomprehendandacton messagesandinvolvesproblemswithmemoryunderstanding orusingwordsandidentifyingobjectsThesignificantly impairedcognitionassociatedwithdementialeadstoalossof senseofselfandoflifelongmemoriesadecreasingabilityto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoMostimportanttoourabilitytoliveourliveswellisthe combinationofmentalprocesseswecalllsquocognitionrsquoor lsquoknowingrsquoThiscombinationincludestheabilitytolearn newthingsintuitionjudgmentlanguageandremembering Havingaclearactivemindatanyageisimportantbutas wegetolderitcanmeanthedifferencebetweendependence andindependentlivingrdquo4
copewiththenormaldemandsoflivingproblemsaccessing healthcaresystemsgreatervulnerabilitytodiseaseinjury malnutritioncrimeandpossiblyabuseandeventuallyaloss ofindependenceThatlossofindependencebecomesaburden onfamiliesandsocietyastheindividualrequiresmoreintense careandofteninstitutionalizationInthelaterstagesthe cognitiveimpairmentassociatedwithdementiawillcreatetotal dependencyandAlzheimerrsquosdiseaseisnowrankedasthe 8th-leadingcauseofdeath5
Why prepare a Road Map
Bringingapublichealthperspectivetocognitivehealth requiresaninclusiveandstrategicapproachMuchimportant workhasalreadybeguninitiatedandsponsoredbyavariety oforganizationsandagenciesatnationalstateandlocallevels (seepages10-11forasamplingofcurrentefforts)
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
OneoftheselandmarkeffortstheNationalInstitutesofHealth (NIH)CognitiveandEmotionalHealthProject(CEHP) wasofficiallylaunchedin2001Selectedexpertsfromseveral universitiesandtheNIHcriticallyanalyzedthescientific literaturetoidentifypossibleriskandprotectivefactorsfor maintainingcognitiveandemotionalhealthinadults6In recognitionoftheimportanceofthiseffortandasfurther testamenttotheincreasedvisibilitythatcognitivehealthis receivingCongressappropriatedfundsinfiscalyear2005to theCentersforDiseaseControlandPrevention(CDC)to addresscognitivehealthwithafocusonlifestyleissuesWith thissupportCDCformedapartnershipwiththeAlzheimerrsquos AssociationandisworkingcloselywiththeNationalInstitute onAgingtheAdministrationonAgingandotherpublicand privatesectororganizationsonaHealthyBrainInitiative
Thispartnership
bull FormedaSteeringCommitteemadeupofnationalexperts toprovideoverallguidanceandcoordinationfortheInitiative (AppendixA)
bull ConvenedaPublicHealthResearchWorkingGroup MeetinginMay2006onThe Healthy Brain and Our Aging PopulationTranslating Science to Public Health PracticeDuring
this2-dayinvitationalmeetingnationalexpertsreviewed researchinpublichealthpreventionrelatedtobrainhealth anddiscussedspecificrecommendationsforaddressingrisk andprotectivefactorsforpromotingcognitivehealthThey focusedonvascularriskfactorsandphysicalactivitybecause oftheirassociationwithcognitiveoutcomes
Thefindingsfromthisresearchmeetingprovidedafoundation andcommonframeofreferenceforthenextstepoftheHealthy BrainInitiativedevelopingstrategicpublichealthrecommenshydationsForthistaskthePartnershipformedworkgroups infourareasofpublichealthactionPreventionResearch CommunicationSurveillanceandPolicyEachworkgroup waschargedwithdraftingrecommendationsformovingthe nationforwardoverthenext3-5yearstowardthelong-term goalofmaintainingandimprovingthecognitivefunctionof adultsKeystakeholdersatthenationalstateandlocallevels thenrefinedtherecommendationsandselectedthoseof highestpriority(AppendixA)
TheNational Public Health Road Map to Maintaining Cognitive Healthreflectstheculminationofthis18-monthprocessAsa cornerstoneoftheInitiativeitoffersapathforhowwecan learnmoreaboutcognitivehealthandthenultimately
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoWearebeginningtotakethe nextstepsbuildingonthe researchcomingoutofNIH andothersandmovingwhat weknowoutintocommunity practiceThisiswherewecan makeadifferenceinthe everydaylivesofAmericansrdquo LyndaAAndersonPhD Healthy Aging Program Centers for Disease Control and Prevention
translatewhatwelearnintoreal-worldpracticetoimprove thehealthofallAmericans
TheauthorsoftheRoadMaprecognizethatinthecourse ofdailylifethedomainsofemotionalandcognitivehealth areinextricablylinkedandcannottrulybeseparatedFor thisRoadMaphoweverweassumethisdistinctionandfocus solelyoncognitivehealthOnlyrecentlyhavepublichealth expertiseandresourcesbeenrecognizedforaddressing cognitivehealthTheRoadMapreflectsacommitmentto bringtheareaofcognitivehealthldquouptoparrdquowithemotional healthastreatmentsandpreventivestrategiesbecomeavailable Itisthefirststepinasystematicprocessforbringingcognitive andemotionalhealthtogetherinamorecomprehensiveand coordinatedpublichealthapproach
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
A Sampling of Current Efforts
Pursuing Research on Factors Influencing Cognitive Health
TheNationalInstitutesofHealth(NIH)isfundingongoing researchtoclarifytherelationshipamongminimizingvascular riskfactorsexerciseotherlifestyleanddruginterventions andcognitivehealthstatusEpidemiologicstudiesare identifyinglikelyriskandprotectivefactorsthesearebeing testedinanimalstudieswhichalsocanhelpidentifythe mechanismsbywhichriskandprotectivefactorsmightwork Inordertoconfirmthattheencouraginginterventions identifiedinepidemiologyandanimalstudiescouldactually maintaincognitivehealthifappliedtohumansclinicaltrials mustbecarriedoutSomearealreadyinprogressbutothers arestillonlyintheplanningphaseNIHkeepsthepublicupshyto-dateonthecurrentstateofthesciencethroughoperation ofaWebsiteandanationalclearinghouse
Assessing Public Perceptions
Formativeresearchwithdiversegroupsisrequiredtohelp gainunderstandingonthepublicrsquosperceptionsaboutcognitive healthOnesucheffortiscurrentlyunderwaywiththesupport ofCDCTheHealthyAgingResearchNetworkwithinits largerPreventionResearchCentersProgram(PRC-HAN) conductspreventionresearchonavarietyofhealthissues involvingolderadultsWithinthePRC-HANmembersare collaboratingonaseriesoffocusgroupsdesignedtoidentify howdiversegroupsofolderadultsunderstandcognitive healthandwhatapproachestohealthpromotionanddisease preventionrelatedtobrainhealththepublicmayfindmost appealingThisprojecthasrecentlybeenexpandedtoexamine theperceptionsofcaregiversandhealthcareprovidersItwill provideimportantdatathatcanbeaddedtowhatisalready knownaboutcognitiveorbrainhealthidentifygapsin knowledgeaboutcognitivehealthandrelatedriskfactors anddeterminewhethersuchbeliefsvaryacrossgeographical distancesandbetweendiversepopulationsFinallythisworkis designedtoleadtothedevelopmentandtestingofashortset ofquestionsthatcanbeusedtoassessthepublicrsquosandpossibly providersrsquoperceptionsaboutcognitivehealthforinclusionin ongoingnationalattitudinalsurveys
0 |TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting Community Education Programs
TheAlzheimerrsquosAssociationhasrecentlylauncheda5-year community-baseddemonstrationprojecttopromoteabrainshyhealthylifestyleThecommunityinterventionisdesignedto affectknowledgeandattitudesamongAfricanAmericanbaby boomersrelatedtophysicalactivityandvascularriskfactors anditwillbeoverlaidwithothergeneralhealthbehaviors suchasdietsocialactivityandmentalactivityDuringthefirst phaseofthisprojecttheAlzheimerrsquosAssociationisleadinga comprehensiveinterventionplanninganddevelopmenteffort includingformativeresearchtoassesscurrentneedsand obstaclesforthetargetpopulationelicitingcommunityinput andparticipationandcreatingacomprehensivemultilevel communityinterventionwithrobustevaluationmechanisms tomeasuretheeffectivenessofthepublichealthprogramin itsnextphase
Developing Common Measures of Cognitive Decline for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativeto developunifiedandintegratedmethodsandmeasuresof cognitiveemotionalmotorandsensoryhealthforusein largecohortstudiesandclinicaltrialsResearchershave expressedtheneedforbriefassessmenttoolsthatcouldbe usedasaformofldquocommoncurrencyrdquoacrossdiversestudy designsandpopulationsThisinitiativewilltakeadvantage ofstate-of-the-artpsychometricresearchandnoveltesting methodstodevelopaninnovativeapproachtoneurological andbehavioralhealthmeasurementUltimatelyitishoped thatthisapproachwillrespondtotheneedsofresearchersin avarietyofsettingswithparticularemphasisonmeasuring outcomesinlargelongitudinalandepidemiologicstudiesand preventionorinterventiontrialsacrossthelifespanWith anavailabletoolboxofmeasuresyieldsfromlargeandvery expensivestudiescanbemaximizedbyallowingamuch largernumberofimportantresearchquestionsregarding neurologicalandbehavioralhealthtobestudiedByensuring thattheassessmentmethodsarecapableofcomparisonto existingandcompletedstudiesandcanincorporatefuture modificationsatrulyldquoeconomicrdquoandvaluablenational resourcefortheentireneurosciencecommunitywillresult
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
Why is it importantmdashand why now
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline
An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10
Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia
bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12
bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ExecutiveSummary
bull Determinehowdiverseaudiencesthinkaboutcognitive healthanditsassociationswithlifestylefactors
bull Disseminatethelatestsciencetoincreasepublicunderstanding ofcognitivehealthandtodispelcommonmisconceptions
bull Helppeopleunderstandtheconnectionbetweenriskand protectivefactorsandcognitivehealth
bull Conductsystematicliteraturereviewsonproposedrisk factors(vascularriskandphysicalinactivity)andrelated interventionsforrelationshipswithcognitivehealthharms gapsandeffectiveness
bull Conductcontrolledclinicaltrialstodeterminetheeffect ofreducingvascularriskfactorsonloweringtheriskof cognitivedeclineandimprovingcognitivefunction
bull Conductcontrolledclinicaltrialstodeterminetheeffectof physicalactivityonreducingtheriskofcognitivedecline andimprovingcognitivefunction
bull Conductresearchonotherareaspotentiallyaffecting cognitivehealthsuchasnutritionmentalactivityand socialengagement
bull Developapopulation-basedsurveillancesystemwith longitudinalfollow-upthatisdedicatedtomeasuringthe publichealthburdenofcognitiveimpairmentinthe UnitedStates
bull Initiatepolicychangesatthefederalstateandlocallevels topromotecognitivehealthbyengagingpublicofficials
bull IncludecognitivehealthinHealthy People 2020aset ofhealthobjectivesforthenationthatwillserveasthe foundationforstateandcommunitypublichealthplans
Itisourhopethatthese10priorityactionswillservetofocus thenationrsquosresourcesonaddressingriskandprotectivefactors forpromotingcognitivehealthoverthenext3-5yearsAsa livingandflexibledocumenttheRoadMaprepresentsboth acalltoactionandaguideforimplementinganeffective coordinatedapproachtomovingcognitivehealthintopublic healthpracticeThekeytosuccessliesincontinuingand expandingresearchdevelopingandchannelingresources workingtodeveloporstrengthenpartnershipswithlikeshymindedorganizationsdesigningcollaborativeoperational plansofactionandestablishingsystemstotrackprogress facilitatecommunicationandexchangeinformation
Continuedvigilanceonthisissueandtimelytranslationof researchfindingsintocommunityactionwillassurethat wereapthepotentialrewardsthatpublichealthcanofferin improvingqualityoflifeamongadultsandreducingsocietal costsforhealthcareandotherservices
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
Background What is cognitive health
Thedistinctionbetweenthemindandbodywasaconcept firstformallysetforthinthe17thcenturybyphilosopher ReneDescartesOverthenextseveralcenturiesthebody wasseenastheconcernofphysicianswhilethemindwas thepurviewoforganizedreligion1
Overtheyearsourunderstandingofldquobodyandmindrdquo hasevolvedsignificantlyWenowrecognizethevitalrole thatbothphysicalhealthandmentalhealthplayinshaping ouroverallwell beingandweappreciatethevaluable contributionsthatawidearrayofhealthprofessionscan maketowardassuringthatwell-being
Background
Mentalhealthencompassesemotionalfunctioningandthe abilitytothinkreasonandremember(cognitivefunctioning) Whilestandardizedwidelyaccepteddefinitionsofcognitive healthhaveyettobeadoptedmostexpertsagreethatthe componentsofhealthycognitive functioning include
bull language bull thought bull memory bull executivefunction(theabilitytoplanandcarryouttasks) bull judgment bull attention bull perception bull rememberedskills(suchasdriving) bull abilitytoliveapurposefullife2
Muchlikephysicalhealthcognitivehealthcanbeviewed alongacontinuummdashfromoptimalfunctioningtomild cognitiveimpairmenttoseveredementiaItisnotsimplythe absenceofdiseasessuchasAlzheimerrsquosdiseaseratheritshould berespectedforitsmultidimensionalnatureandthechanges thattakeplaceoverthelifespanshouldbeacceptedeven embracedasanaturalpartoftheagingprocess3
Cognitivedeclinecanrangefrommildcognitiveimpairment todementiabutthesetwoconditionsarenotnecessarily manifestationsofthesamediseaseManypeoplenever developanyseriousdeclineintheircognitiveperformance andthosewhodevelopmildcognitiveproblemsdonot necessarilydevelopdementiaAlthoughnotallpeoplewith cognitivedeclinedevelopdementiathosewithanamnestic formofmildcognitiveimpairmentdohaveamuchhigher riskfordementiathanotheradults
Thelackofcognitivehealthcanhaveprofoundimplications forapersonrsquosphysicalhealthOlderadultsandothers experiencingcognitiveimpairmentmaybeunabletocare forthemselvesortoengageinnecessaryactivitiesofdaily livingsuchaspreparingmealsormanagingtheirfinances Limitationsintheabilitytoeffectivelymanagemedications andexistingmedicalconditionsareofparticularconcernwhen apersonisexperiencingcognitiveimpairmentordementia
Dementiaaffectsapersonrsquosabilitytocomprehendandacton messagesandinvolvesproblemswithmemoryunderstanding orusingwordsandidentifyingobjectsThesignificantly impairedcognitionassociatedwithdementialeadstoalossof senseofselfandoflifelongmemoriesadecreasingabilityto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoMostimportanttoourabilitytoliveourliveswellisthe combinationofmentalprocesseswecalllsquocognitionrsquoor lsquoknowingrsquoThiscombinationincludestheabilitytolearn newthingsintuitionjudgmentlanguageandremembering Havingaclearactivemindatanyageisimportantbutas wegetolderitcanmeanthedifferencebetweendependence andindependentlivingrdquo4
copewiththenormaldemandsoflivingproblemsaccessing healthcaresystemsgreatervulnerabilitytodiseaseinjury malnutritioncrimeandpossiblyabuseandeventuallyaloss ofindependenceThatlossofindependencebecomesaburden onfamiliesandsocietyastheindividualrequiresmoreintense careandofteninstitutionalizationInthelaterstagesthe cognitiveimpairmentassociatedwithdementiawillcreatetotal dependencyandAlzheimerrsquosdiseaseisnowrankedasthe 8th-leadingcauseofdeath5
Why prepare a Road Map
Bringingapublichealthperspectivetocognitivehealth requiresaninclusiveandstrategicapproachMuchimportant workhasalreadybeguninitiatedandsponsoredbyavariety oforganizationsandagenciesatnationalstateandlocallevels (seepages10-11forasamplingofcurrentefforts)
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
OneoftheselandmarkeffortstheNationalInstitutesofHealth (NIH)CognitiveandEmotionalHealthProject(CEHP) wasofficiallylaunchedin2001Selectedexpertsfromseveral universitiesandtheNIHcriticallyanalyzedthescientific literaturetoidentifypossibleriskandprotectivefactorsfor maintainingcognitiveandemotionalhealthinadults6In recognitionoftheimportanceofthiseffortandasfurther testamenttotheincreasedvisibilitythatcognitivehealthis receivingCongressappropriatedfundsinfiscalyear2005to theCentersforDiseaseControlandPrevention(CDC)to addresscognitivehealthwithafocusonlifestyleissuesWith thissupportCDCformedapartnershipwiththeAlzheimerrsquos AssociationandisworkingcloselywiththeNationalInstitute onAgingtheAdministrationonAgingandotherpublicand privatesectororganizationsonaHealthyBrainInitiative
Thispartnership
bull FormedaSteeringCommitteemadeupofnationalexperts toprovideoverallguidanceandcoordinationfortheInitiative (AppendixA)
bull ConvenedaPublicHealthResearchWorkingGroup MeetinginMay2006onThe Healthy Brain and Our Aging PopulationTranslating Science to Public Health PracticeDuring
this2-dayinvitationalmeetingnationalexpertsreviewed researchinpublichealthpreventionrelatedtobrainhealth anddiscussedspecificrecommendationsforaddressingrisk andprotectivefactorsforpromotingcognitivehealthThey focusedonvascularriskfactorsandphysicalactivitybecause oftheirassociationwithcognitiveoutcomes
Thefindingsfromthisresearchmeetingprovidedafoundation andcommonframeofreferenceforthenextstepoftheHealthy BrainInitiativedevelopingstrategicpublichealthrecommenshydationsForthistaskthePartnershipformedworkgroups infourareasofpublichealthactionPreventionResearch CommunicationSurveillanceandPolicyEachworkgroup waschargedwithdraftingrecommendationsformovingthe nationforwardoverthenext3-5yearstowardthelong-term goalofmaintainingandimprovingthecognitivefunctionof adultsKeystakeholdersatthenationalstateandlocallevels thenrefinedtherecommendationsandselectedthoseof highestpriority(AppendixA)
TheNational Public Health Road Map to Maintaining Cognitive Healthreflectstheculminationofthis18-monthprocessAsa cornerstoneoftheInitiativeitoffersapathforhowwecan learnmoreaboutcognitivehealthandthenultimately
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoWearebeginningtotakethe nextstepsbuildingonthe researchcomingoutofNIH andothersandmovingwhat weknowoutintocommunity practiceThisiswherewecan makeadifferenceinthe everydaylivesofAmericansrdquo LyndaAAndersonPhD Healthy Aging Program Centers for Disease Control and Prevention
translatewhatwelearnintoreal-worldpracticetoimprove thehealthofallAmericans
TheauthorsoftheRoadMaprecognizethatinthecourse ofdailylifethedomainsofemotionalandcognitivehealth areinextricablylinkedandcannottrulybeseparatedFor thisRoadMaphoweverweassumethisdistinctionandfocus solelyoncognitivehealthOnlyrecentlyhavepublichealth expertiseandresourcesbeenrecognizedforaddressing cognitivehealthTheRoadMapreflectsacommitmentto bringtheareaofcognitivehealthldquouptoparrdquowithemotional healthastreatmentsandpreventivestrategiesbecomeavailable Itisthefirststepinasystematicprocessforbringingcognitive andemotionalhealthtogetherinamorecomprehensiveand coordinatedpublichealthapproach
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
A Sampling of Current Efforts
Pursuing Research on Factors Influencing Cognitive Health
TheNationalInstitutesofHealth(NIH)isfundingongoing researchtoclarifytherelationshipamongminimizingvascular riskfactorsexerciseotherlifestyleanddruginterventions andcognitivehealthstatusEpidemiologicstudiesare identifyinglikelyriskandprotectivefactorsthesearebeing testedinanimalstudieswhichalsocanhelpidentifythe mechanismsbywhichriskandprotectivefactorsmightwork Inordertoconfirmthattheencouraginginterventions identifiedinepidemiologyandanimalstudiescouldactually maintaincognitivehealthifappliedtohumansclinicaltrials mustbecarriedoutSomearealreadyinprogressbutothers arestillonlyintheplanningphaseNIHkeepsthepublicupshyto-dateonthecurrentstateofthesciencethroughoperation ofaWebsiteandanationalclearinghouse
Assessing Public Perceptions
Formativeresearchwithdiversegroupsisrequiredtohelp gainunderstandingonthepublicrsquosperceptionsaboutcognitive healthOnesucheffortiscurrentlyunderwaywiththesupport ofCDCTheHealthyAgingResearchNetworkwithinits largerPreventionResearchCentersProgram(PRC-HAN) conductspreventionresearchonavarietyofhealthissues involvingolderadultsWithinthePRC-HANmembersare collaboratingonaseriesoffocusgroupsdesignedtoidentify howdiversegroupsofolderadultsunderstandcognitive healthandwhatapproachestohealthpromotionanddisease preventionrelatedtobrainhealththepublicmayfindmost appealingThisprojecthasrecentlybeenexpandedtoexamine theperceptionsofcaregiversandhealthcareprovidersItwill provideimportantdatathatcanbeaddedtowhatisalready knownaboutcognitiveorbrainhealthidentifygapsin knowledgeaboutcognitivehealthandrelatedriskfactors anddeterminewhethersuchbeliefsvaryacrossgeographical distancesandbetweendiversepopulationsFinallythisworkis designedtoleadtothedevelopmentandtestingofashortset ofquestionsthatcanbeusedtoassessthepublicrsquosandpossibly providersrsquoperceptionsaboutcognitivehealthforinclusionin ongoingnationalattitudinalsurveys
0 |TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting Community Education Programs
TheAlzheimerrsquosAssociationhasrecentlylauncheda5-year community-baseddemonstrationprojecttopromoteabrainshyhealthylifestyleThecommunityinterventionisdesignedto affectknowledgeandattitudesamongAfricanAmericanbaby boomersrelatedtophysicalactivityandvascularriskfactors anditwillbeoverlaidwithothergeneralhealthbehaviors suchasdietsocialactivityandmentalactivityDuringthefirst phaseofthisprojecttheAlzheimerrsquosAssociationisleadinga comprehensiveinterventionplanninganddevelopmenteffort includingformativeresearchtoassesscurrentneedsand obstaclesforthetargetpopulationelicitingcommunityinput andparticipationandcreatingacomprehensivemultilevel communityinterventionwithrobustevaluationmechanisms tomeasuretheeffectivenessofthepublichealthprogramin itsnextphase
Developing Common Measures of Cognitive Decline for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativeto developunifiedandintegratedmethodsandmeasuresof cognitiveemotionalmotorandsensoryhealthforusein largecohortstudiesandclinicaltrialsResearchershave expressedtheneedforbriefassessmenttoolsthatcouldbe usedasaformofldquocommoncurrencyrdquoacrossdiversestudy designsandpopulationsThisinitiativewilltakeadvantage ofstate-of-the-artpsychometricresearchandnoveltesting methodstodevelopaninnovativeapproachtoneurological andbehavioralhealthmeasurementUltimatelyitishoped thatthisapproachwillrespondtotheneedsofresearchersin avarietyofsettingswithparticularemphasisonmeasuring outcomesinlargelongitudinalandepidemiologicstudiesand preventionorinterventiontrialsacrossthelifespanWith anavailabletoolboxofmeasuresyieldsfromlargeandvery expensivestudiescanbemaximizedbyallowingamuch largernumberofimportantresearchquestionsregarding neurologicalandbehavioralhealthtobestudiedByensuring thattheassessmentmethodsarecapableofcomparisonto existingandcompletedstudiesandcanincorporatefuture modificationsatrulyldquoeconomicrdquoandvaluablenational resourcefortheentireneurosciencecommunitywillresult
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
Why is it importantmdashand why now
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline
An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10
Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia
bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12
bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
Background What is cognitive health
Thedistinctionbetweenthemindandbodywasaconcept firstformallysetforthinthe17thcenturybyphilosopher ReneDescartesOverthenextseveralcenturiesthebody wasseenastheconcernofphysicianswhilethemindwas thepurviewoforganizedreligion1
Overtheyearsourunderstandingofldquobodyandmindrdquo hasevolvedsignificantlyWenowrecognizethevitalrole thatbothphysicalhealthandmentalhealthplayinshaping ouroverallwell beingandweappreciatethevaluable contributionsthatawidearrayofhealthprofessionscan maketowardassuringthatwell-being
Background
Mentalhealthencompassesemotionalfunctioningandthe abilitytothinkreasonandremember(cognitivefunctioning) Whilestandardizedwidelyaccepteddefinitionsofcognitive healthhaveyettobeadoptedmostexpertsagreethatthe componentsofhealthycognitive functioning include
bull language bull thought bull memory bull executivefunction(theabilitytoplanandcarryouttasks) bull judgment bull attention bull perception bull rememberedskills(suchasdriving) bull abilitytoliveapurposefullife2
Muchlikephysicalhealthcognitivehealthcanbeviewed alongacontinuummdashfromoptimalfunctioningtomild cognitiveimpairmenttoseveredementiaItisnotsimplythe absenceofdiseasessuchasAlzheimerrsquosdiseaseratheritshould berespectedforitsmultidimensionalnatureandthechanges thattakeplaceoverthelifespanshouldbeacceptedeven embracedasanaturalpartoftheagingprocess3
Cognitivedeclinecanrangefrommildcognitiveimpairment todementiabutthesetwoconditionsarenotnecessarily manifestationsofthesamediseaseManypeoplenever developanyseriousdeclineintheircognitiveperformance andthosewhodevelopmildcognitiveproblemsdonot necessarilydevelopdementiaAlthoughnotallpeoplewith cognitivedeclinedevelopdementiathosewithanamnestic formofmildcognitiveimpairmentdohaveamuchhigher riskfordementiathanotheradults
Thelackofcognitivehealthcanhaveprofoundimplications forapersonrsquosphysicalhealthOlderadultsandothers experiencingcognitiveimpairmentmaybeunabletocare forthemselvesortoengageinnecessaryactivitiesofdaily livingsuchaspreparingmealsormanagingtheirfinances Limitationsintheabilitytoeffectivelymanagemedications andexistingmedicalconditionsareofparticularconcernwhen apersonisexperiencingcognitiveimpairmentordementia
Dementiaaffectsapersonrsquosabilitytocomprehendandacton messagesandinvolvesproblemswithmemoryunderstanding orusingwordsandidentifyingobjectsThesignificantly impairedcognitionassociatedwithdementialeadstoalossof senseofselfandoflifelongmemoriesadecreasingabilityto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoMostimportanttoourabilitytoliveourliveswellisthe combinationofmentalprocesseswecalllsquocognitionrsquoor lsquoknowingrsquoThiscombinationincludestheabilitytolearn newthingsintuitionjudgmentlanguageandremembering Havingaclearactivemindatanyageisimportantbutas wegetolderitcanmeanthedifferencebetweendependence andindependentlivingrdquo4
copewiththenormaldemandsoflivingproblemsaccessing healthcaresystemsgreatervulnerabilitytodiseaseinjury malnutritioncrimeandpossiblyabuseandeventuallyaloss ofindependenceThatlossofindependencebecomesaburden onfamiliesandsocietyastheindividualrequiresmoreintense careandofteninstitutionalizationInthelaterstagesthe cognitiveimpairmentassociatedwithdementiawillcreatetotal dependencyandAlzheimerrsquosdiseaseisnowrankedasthe 8th-leadingcauseofdeath5
Why prepare a Road Map
Bringingapublichealthperspectivetocognitivehealth requiresaninclusiveandstrategicapproachMuchimportant workhasalreadybeguninitiatedandsponsoredbyavariety oforganizationsandagenciesatnationalstateandlocallevels (seepages10-11forasamplingofcurrentefforts)
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
OneoftheselandmarkeffortstheNationalInstitutesofHealth (NIH)CognitiveandEmotionalHealthProject(CEHP) wasofficiallylaunchedin2001Selectedexpertsfromseveral universitiesandtheNIHcriticallyanalyzedthescientific literaturetoidentifypossibleriskandprotectivefactorsfor maintainingcognitiveandemotionalhealthinadults6In recognitionoftheimportanceofthiseffortandasfurther testamenttotheincreasedvisibilitythatcognitivehealthis receivingCongressappropriatedfundsinfiscalyear2005to theCentersforDiseaseControlandPrevention(CDC)to addresscognitivehealthwithafocusonlifestyleissuesWith thissupportCDCformedapartnershipwiththeAlzheimerrsquos AssociationandisworkingcloselywiththeNationalInstitute onAgingtheAdministrationonAgingandotherpublicand privatesectororganizationsonaHealthyBrainInitiative
Thispartnership
bull FormedaSteeringCommitteemadeupofnationalexperts toprovideoverallguidanceandcoordinationfortheInitiative (AppendixA)
bull ConvenedaPublicHealthResearchWorkingGroup MeetinginMay2006onThe Healthy Brain and Our Aging PopulationTranslating Science to Public Health PracticeDuring
this2-dayinvitationalmeetingnationalexpertsreviewed researchinpublichealthpreventionrelatedtobrainhealth anddiscussedspecificrecommendationsforaddressingrisk andprotectivefactorsforpromotingcognitivehealthThey focusedonvascularriskfactorsandphysicalactivitybecause oftheirassociationwithcognitiveoutcomes
Thefindingsfromthisresearchmeetingprovidedafoundation andcommonframeofreferenceforthenextstepoftheHealthy BrainInitiativedevelopingstrategicpublichealthrecommenshydationsForthistaskthePartnershipformedworkgroups infourareasofpublichealthactionPreventionResearch CommunicationSurveillanceandPolicyEachworkgroup waschargedwithdraftingrecommendationsformovingthe nationforwardoverthenext3-5yearstowardthelong-term goalofmaintainingandimprovingthecognitivefunctionof adultsKeystakeholdersatthenationalstateandlocallevels thenrefinedtherecommendationsandselectedthoseof highestpriority(AppendixA)
TheNational Public Health Road Map to Maintaining Cognitive Healthreflectstheculminationofthis18-monthprocessAsa cornerstoneoftheInitiativeitoffersapathforhowwecan learnmoreaboutcognitivehealthandthenultimately
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoWearebeginningtotakethe nextstepsbuildingonthe researchcomingoutofNIH andothersandmovingwhat weknowoutintocommunity practiceThisiswherewecan makeadifferenceinthe everydaylivesofAmericansrdquo LyndaAAndersonPhD Healthy Aging Program Centers for Disease Control and Prevention
translatewhatwelearnintoreal-worldpracticetoimprove thehealthofallAmericans
TheauthorsoftheRoadMaprecognizethatinthecourse ofdailylifethedomainsofemotionalandcognitivehealth areinextricablylinkedandcannottrulybeseparatedFor thisRoadMaphoweverweassumethisdistinctionandfocus solelyoncognitivehealthOnlyrecentlyhavepublichealth expertiseandresourcesbeenrecognizedforaddressing cognitivehealthTheRoadMapreflectsacommitmentto bringtheareaofcognitivehealthldquouptoparrdquowithemotional healthastreatmentsandpreventivestrategiesbecomeavailable Itisthefirststepinasystematicprocessforbringingcognitive andemotionalhealthtogetherinamorecomprehensiveand coordinatedpublichealthapproach
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
A Sampling of Current Efforts
Pursuing Research on Factors Influencing Cognitive Health
TheNationalInstitutesofHealth(NIH)isfundingongoing researchtoclarifytherelationshipamongminimizingvascular riskfactorsexerciseotherlifestyleanddruginterventions andcognitivehealthstatusEpidemiologicstudiesare identifyinglikelyriskandprotectivefactorsthesearebeing testedinanimalstudieswhichalsocanhelpidentifythe mechanismsbywhichriskandprotectivefactorsmightwork Inordertoconfirmthattheencouraginginterventions identifiedinepidemiologyandanimalstudiescouldactually maintaincognitivehealthifappliedtohumansclinicaltrials mustbecarriedoutSomearealreadyinprogressbutothers arestillonlyintheplanningphaseNIHkeepsthepublicupshyto-dateonthecurrentstateofthesciencethroughoperation ofaWebsiteandanationalclearinghouse
Assessing Public Perceptions
Formativeresearchwithdiversegroupsisrequiredtohelp gainunderstandingonthepublicrsquosperceptionsaboutcognitive healthOnesucheffortiscurrentlyunderwaywiththesupport ofCDCTheHealthyAgingResearchNetworkwithinits largerPreventionResearchCentersProgram(PRC-HAN) conductspreventionresearchonavarietyofhealthissues involvingolderadultsWithinthePRC-HANmembersare collaboratingonaseriesoffocusgroupsdesignedtoidentify howdiversegroupsofolderadultsunderstandcognitive healthandwhatapproachestohealthpromotionanddisease preventionrelatedtobrainhealththepublicmayfindmost appealingThisprojecthasrecentlybeenexpandedtoexamine theperceptionsofcaregiversandhealthcareprovidersItwill provideimportantdatathatcanbeaddedtowhatisalready knownaboutcognitiveorbrainhealthidentifygapsin knowledgeaboutcognitivehealthandrelatedriskfactors anddeterminewhethersuchbeliefsvaryacrossgeographical distancesandbetweendiversepopulationsFinallythisworkis designedtoleadtothedevelopmentandtestingofashortset ofquestionsthatcanbeusedtoassessthepublicrsquosandpossibly providersrsquoperceptionsaboutcognitivehealthforinclusionin ongoingnationalattitudinalsurveys
0 |TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting Community Education Programs
TheAlzheimerrsquosAssociationhasrecentlylauncheda5-year community-baseddemonstrationprojecttopromoteabrainshyhealthylifestyleThecommunityinterventionisdesignedto affectknowledgeandattitudesamongAfricanAmericanbaby boomersrelatedtophysicalactivityandvascularriskfactors anditwillbeoverlaidwithothergeneralhealthbehaviors suchasdietsocialactivityandmentalactivityDuringthefirst phaseofthisprojecttheAlzheimerrsquosAssociationisleadinga comprehensiveinterventionplanninganddevelopmenteffort includingformativeresearchtoassesscurrentneedsand obstaclesforthetargetpopulationelicitingcommunityinput andparticipationandcreatingacomprehensivemultilevel communityinterventionwithrobustevaluationmechanisms tomeasuretheeffectivenessofthepublichealthprogramin itsnextphase
Developing Common Measures of Cognitive Decline for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativeto developunifiedandintegratedmethodsandmeasuresof cognitiveemotionalmotorandsensoryhealthforusein largecohortstudiesandclinicaltrialsResearchershave expressedtheneedforbriefassessmenttoolsthatcouldbe usedasaformofldquocommoncurrencyrdquoacrossdiversestudy designsandpopulationsThisinitiativewilltakeadvantage ofstate-of-the-artpsychometricresearchandnoveltesting methodstodevelopaninnovativeapproachtoneurological andbehavioralhealthmeasurementUltimatelyitishoped thatthisapproachwillrespondtotheneedsofresearchersin avarietyofsettingswithparticularemphasisonmeasuring outcomesinlargelongitudinalandepidemiologicstudiesand preventionorinterventiontrialsacrossthelifespanWith anavailabletoolboxofmeasuresyieldsfromlargeandvery expensivestudiescanbemaximizedbyallowingamuch largernumberofimportantresearchquestionsregarding neurologicalandbehavioralhealthtobestudiedByensuring thattheassessmentmethodsarecapableofcomparisonto existingandcompletedstudiesandcanincorporatefuture modificationsatrulyldquoeconomicrdquoandvaluablenational resourcefortheentireneurosciencecommunitywillresult
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
Why is it importantmdashand why now
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline
An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10
Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia
bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12
bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
Background What is cognitive health
Thedistinctionbetweenthemindandbodywasaconcept firstformallysetforthinthe17thcenturybyphilosopher ReneDescartesOverthenextseveralcenturiesthebody wasseenastheconcernofphysicianswhilethemindwas thepurviewoforganizedreligion1
Overtheyearsourunderstandingofldquobodyandmindrdquo hasevolvedsignificantlyWenowrecognizethevitalrole thatbothphysicalhealthandmentalhealthplayinshaping ouroverallwell beingandweappreciatethevaluable contributionsthatawidearrayofhealthprofessionscan maketowardassuringthatwell-being
Background
Mentalhealthencompassesemotionalfunctioningandthe abilitytothinkreasonandremember(cognitivefunctioning) Whilestandardizedwidelyaccepteddefinitionsofcognitive healthhaveyettobeadoptedmostexpertsagreethatthe componentsofhealthycognitive functioning include
bull language bull thought bull memory bull executivefunction(theabilitytoplanandcarryouttasks) bull judgment bull attention bull perception bull rememberedskills(suchasdriving) bull abilitytoliveapurposefullife2
Muchlikephysicalhealthcognitivehealthcanbeviewed alongacontinuummdashfromoptimalfunctioningtomild cognitiveimpairmenttoseveredementiaItisnotsimplythe absenceofdiseasessuchasAlzheimerrsquosdiseaseratheritshould berespectedforitsmultidimensionalnatureandthechanges thattakeplaceoverthelifespanshouldbeacceptedeven embracedasanaturalpartoftheagingprocess3
Cognitivedeclinecanrangefrommildcognitiveimpairment todementiabutthesetwoconditionsarenotnecessarily manifestationsofthesamediseaseManypeoplenever developanyseriousdeclineintheircognitiveperformance andthosewhodevelopmildcognitiveproblemsdonot necessarilydevelopdementiaAlthoughnotallpeoplewith cognitivedeclinedevelopdementiathosewithanamnestic formofmildcognitiveimpairmentdohaveamuchhigher riskfordementiathanotheradults
Thelackofcognitivehealthcanhaveprofoundimplications forapersonrsquosphysicalhealthOlderadultsandothers experiencingcognitiveimpairmentmaybeunabletocare forthemselvesortoengageinnecessaryactivitiesofdaily livingsuchaspreparingmealsormanagingtheirfinances Limitationsintheabilitytoeffectivelymanagemedications andexistingmedicalconditionsareofparticularconcernwhen apersonisexperiencingcognitiveimpairmentordementia
Dementiaaffectsapersonrsquosabilitytocomprehendandacton messagesandinvolvesproblemswithmemoryunderstanding orusingwordsandidentifyingobjectsThesignificantly impairedcognitionassociatedwithdementialeadstoalossof senseofselfandoflifelongmemoriesadecreasingabilityto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoMostimportanttoourabilitytoliveourliveswellisthe combinationofmentalprocesseswecalllsquocognitionrsquoor lsquoknowingrsquoThiscombinationincludestheabilitytolearn newthingsintuitionjudgmentlanguageandremembering Havingaclearactivemindatanyageisimportantbutas wegetolderitcanmeanthedifferencebetweendependence andindependentlivingrdquo4
copewiththenormaldemandsoflivingproblemsaccessing healthcaresystemsgreatervulnerabilitytodiseaseinjury malnutritioncrimeandpossiblyabuseandeventuallyaloss ofindependenceThatlossofindependencebecomesaburden onfamiliesandsocietyastheindividualrequiresmoreintense careandofteninstitutionalizationInthelaterstagesthe cognitiveimpairmentassociatedwithdementiawillcreatetotal dependencyandAlzheimerrsquosdiseaseisnowrankedasthe 8th-leadingcauseofdeath5
Why prepare a Road Map
Bringingapublichealthperspectivetocognitivehealth requiresaninclusiveandstrategicapproachMuchimportant workhasalreadybeguninitiatedandsponsoredbyavariety oforganizationsandagenciesatnationalstateandlocallevels (seepages10-11forasamplingofcurrentefforts)
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
OneoftheselandmarkeffortstheNationalInstitutesofHealth (NIH)CognitiveandEmotionalHealthProject(CEHP) wasofficiallylaunchedin2001Selectedexpertsfromseveral universitiesandtheNIHcriticallyanalyzedthescientific literaturetoidentifypossibleriskandprotectivefactorsfor maintainingcognitiveandemotionalhealthinadults6In recognitionoftheimportanceofthiseffortandasfurther testamenttotheincreasedvisibilitythatcognitivehealthis receivingCongressappropriatedfundsinfiscalyear2005to theCentersforDiseaseControlandPrevention(CDC)to addresscognitivehealthwithafocusonlifestyleissuesWith thissupportCDCformedapartnershipwiththeAlzheimerrsquos AssociationandisworkingcloselywiththeNationalInstitute onAgingtheAdministrationonAgingandotherpublicand privatesectororganizationsonaHealthyBrainInitiative
Thispartnership
bull FormedaSteeringCommitteemadeupofnationalexperts toprovideoverallguidanceandcoordinationfortheInitiative (AppendixA)
bull ConvenedaPublicHealthResearchWorkingGroup MeetinginMay2006onThe Healthy Brain and Our Aging PopulationTranslating Science to Public Health PracticeDuring
this2-dayinvitationalmeetingnationalexpertsreviewed researchinpublichealthpreventionrelatedtobrainhealth anddiscussedspecificrecommendationsforaddressingrisk andprotectivefactorsforpromotingcognitivehealthThey focusedonvascularriskfactorsandphysicalactivitybecause oftheirassociationwithcognitiveoutcomes
Thefindingsfromthisresearchmeetingprovidedafoundation andcommonframeofreferenceforthenextstepoftheHealthy BrainInitiativedevelopingstrategicpublichealthrecommenshydationsForthistaskthePartnershipformedworkgroups infourareasofpublichealthactionPreventionResearch CommunicationSurveillanceandPolicyEachworkgroup waschargedwithdraftingrecommendationsformovingthe nationforwardoverthenext3-5yearstowardthelong-term goalofmaintainingandimprovingthecognitivefunctionof adultsKeystakeholdersatthenationalstateandlocallevels thenrefinedtherecommendationsandselectedthoseof highestpriority(AppendixA)
TheNational Public Health Road Map to Maintaining Cognitive Healthreflectstheculminationofthis18-monthprocessAsa cornerstoneoftheInitiativeitoffersapathforhowwecan learnmoreaboutcognitivehealthandthenultimately
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoWearebeginningtotakethe nextstepsbuildingonthe researchcomingoutofNIH andothersandmovingwhat weknowoutintocommunity practiceThisiswherewecan makeadifferenceinthe everydaylivesofAmericansrdquo LyndaAAndersonPhD Healthy Aging Program Centers for Disease Control and Prevention
translatewhatwelearnintoreal-worldpracticetoimprove thehealthofallAmericans
TheauthorsoftheRoadMaprecognizethatinthecourse ofdailylifethedomainsofemotionalandcognitivehealth areinextricablylinkedandcannottrulybeseparatedFor thisRoadMaphoweverweassumethisdistinctionandfocus solelyoncognitivehealthOnlyrecentlyhavepublichealth expertiseandresourcesbeenrecognizedforaddressing cognitivehealthTheRoadMapreflectsacommitmentto bringtheareaofcognitivehealthldquouptoparrdquowithemotional healthastreatmentsandpreventivestrategiesbecomeavailable Itisthefirststepinasystematicprocessforbringingcognitive andemotionalhealthtogetherinamorecomprehensiveand coordinatedpublichealthapproach
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
A Sampling of Current Efforts
Pursuing Research on Factors Influencing Cognitive Health
TheNationalInstitutesofHealth(NIH)isfundingongoing researchtoclarifytherelationshipamongminimizingvascular riskfactorsexerciseotherlifestyleanddruginterventions andcognitivehealthstatusEpidemiologicstudiesare identifyinglikelyriskandprotectivefactorsthesearebeing testedinanimalstudieswhichalsocanhelpidentifythe mechanismsbywhichriskandprotectivefactorsmightwork Inordertoconfirmthattheencouraginginterventions identifiedinepidemiologyandanimalstudiescouldactually maintaincognitivehealthifappliedtohumansclinicaltrials mustbecarriedoutSomearealreadyinprogressbutothers arestillonlyintheplanningphaseNIHkeepsthepublicupshyto-dateonthecurrentstateofthesciencethroughoperation ofaWebsiteandanationalclearinghouse
Assessing Public Perceptions
Formativeresearchwithdiversegroupsisrequiredtohelp gainunderstandingonthepublicrsquosperceptionsaboutcognitive healthOnesucheffortiscurrentlyunderwaywiththesupport ofCDCTheHealthyAgingResearchNetworkwithinits largerPreventionResearchCentersProgram(PRC-HAN) conductspreventionresearchonavarietyofhealthissues involvingolderadultsWithinthePRC-HANmembersare collaboratingonaseriesoffocusgroupsdesignedtoidentify howdiversegroupsofolderadultsunderstandcognitive healthandwhatapproachestohealthpromotionanddisease preventionrelatedtobrainhealththepublicmayfindmost appealingThisprojecthasrecentlybeenexpandedtoexamine theperceptionsofcaregiversandhealthcareprovidersItwill provideimportantdatathatcanbeaddedtowhatisalready knownaboutcognitiveorbrainhealthidentifygapsin knowledgeaboutcognitivehealthandrelatedriskfactors anddeterminewhethersuchbeliefsvaryacrossgeographical distancesandbetweendiversepopulationsFinallythisworkis designedtoleadtothedevelopmentandtestingofashortset ofquestionsthatcanbeusedtoassessthepublicrsquosandpossibly providersrsquoperceptionsaboutcognitivehealthforinclusionin ongoingnationalattitudinalsurveys
0 |TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting Community Education Programs
TheAlzheimerrsquosAssociationhasrecentlylauncheda5-year community-baseddemonstrationprojecttopromoteabrainshyhealthylifestyleThecommunityinterventionisdesignedto affectknowledgeandattitudesamongAfricanAmericanbaby boomersrelatedtophysicalactivityandvascularriskfactors anditwillbeoverlaidwithothergeneralhealthbehaviors suchasdietsocialactivityandmentalactivityDuringthefirst phaseofthisprojecttheAlzheimerrsquosAssociationisleadinga comprehensiveinterventionplanninganddevelopmenteffort includingformativeresearchtoassesscurrentneedsand obstaclesforthetargetpopulationelicitingcommunityinput andparticipationandcreatingacomprehensivemultilevel communityinterventionwithrobustevaluationmechanisms tomeasuretheeffectivenessofthepublichealthprogramin itsnextphase
Developing Common Measures of Cognitive Decline for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativeto developunifiedandintegratedmethodsandmeasuresof cognitiveemotionalmotorandsensoryhealthforusein largecohortstudiesandclinicaltrialsResearchershave expressedtheneedforbriefassessmenttoolsthatcouldbe usedasaformofldquocommoncurrencyrdquoacrossdiversestudy designsandpopulationsThisinitiativewilltakeadvantage ofstate-of-the-artpsychometricresearchandnoveltesting methodstodevelopaninnovativeapproachtoneurological andbehavioralhealthmeasurementUltimatelyitishoped thatthisapproachwillrespondtotheneedsofresearchersin avarietyofsettingswithparticularemphasisonmeasuring outcomesinlargelongitudinalandepidemiologicstudiesand preventionorinterventiontrialsacrossthelifespanWith anavailabletoolboxofmeasuresyieldsfromlargeandvery expensivestudiescanbemaximizedbyallowingamuch largernumberofimportantresearchquestionsregarding neurologicalandbehavioralhealthtobestudiedByensuring thattheassessmentmethodsarecapableofcomparisonto existingandcompletedstudiesandcanincorporatefuture modificationsatrulyldquoeconomicrdquoandvaluablenational resourcefortheentireneurosciencecommunitywillresult
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
Why is it importantmdashand why now
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline
An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10
Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia
bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12
bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Background
Mentalhealthencompassesemotionalfunctioningandthe abilitytothinkreasonandremember(cognitivefunctioning) Whilestandardizedwidelyaccepteddefinitionsofcognitive healthhaveyettobeadoptedmostexpertsagreethatthe componentsofhealthycognitive functioning include
bull language bull thought bull memory bull executivefunction(theabilitytoplanandcarryouttasks) bull judgment bull attention bull perception bull rememberedskills(suchasdriving) bull abilitytoliveapurposefullife2
Muchlikephysicalhealthcognitivehealthcanbeviewed alongacontinuummdashfromoptimalfunctioningtomild cognitiveimpairmenttoseveredementiaItisnotsimplythe absenceofdiseasessuchasAlzheimerrsquosdiseaseratheritshould berespectedforitsmultidimensionalnatureandthechanges thattakeplaceoverthelifespanshouldbeacceptedeven embracedasanaturalpartoftheagingprocess3
Cognitivedeclinecanrangefrommildcognitiveimpairment todementiabutthesetwoconditionsarenotnecessarily manifestationsofthesamediseaseManypeoplenever developanyseriousdeclineintheircognitiveperformance andthosewhodevelopmildcognitiveproblemsdonot necessarilydevelopdementiaAlthoughnotallpeoplewith cognitivedeclinedevelopdementiathosewithanamnestic formofmildcognitiveimpairmentdohaveamuchhigher riskfordementiathanotheradults
Thelackofcognitivehealthcanhaveprofoundimplications forapersonrsquosphysicalhealthOlderadultsandothers experiencingcognitiveimpairmentmaybeunabletocare forthemselvesortoengageinnecessaryactivitiesofdaily livingsuchaspreparingmealsormanagingtheirfinances Limitationsintheabilitytoeffectivelymanagemedications andexistingmedicalconditionsareofparticularconcernwhen apersonisexperiencingcognitiveimpairmentordementia
Dementiaaffectsapersonrsquosabilitytocomprehendandacton messagesandinvolvesproblemswithmemoryunderstanding orusingwordsandidentifyingobjectsThesignificantly impairedcognitionassociatedwithdementialeadstoalossof senseofselfandoflifelongmemoriesadecreasingabilityto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoMostimportanttoourabilitytoliveourliveswellisthe combinationofmentalprocesseswecalllsquocognitionrsquoor lsquoknowingrsquoThiscombinationincludestheabilitytolearn newthingsintuitionjudgmentlanguageandremembering Havingaclearactivemindatanyageisimportantbutas wegetolderitcanmeanthedifferencebetweendependence andindependentlivingrdquo4
copewiththenormaldemandsoflivingproblemsaccessing healthcaresystemsgreatervulnerabilitytodiseaseinjury malnutritioncrimeandpossiblyabuseandeventuallyaloss ofindependenceThatlossofindependencebecomesaburden onfamiliesandsocietyastheindividualrequiresmoreintense careandofteninstitutionalizationInthelaterstagesthe cognitiveimpairmentassociatedwithdementiawillcreatetotal dependencyandAlzheimerrsquosdiseaseisnowrankedasthe 8th-leadingcauseofdeath5
Why prepare a Road Map
Bringingapublichealthperspectivetocognitivehealth requiresaninclusiveandstrategicapproachMuchimportant workhasalreadybeguninitiatedandsponsoredbyavariety oforganizationsandagenciesatnationalstateandlocallevels (seepages10-11forasamplingofcurrentefforts)
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
OneoftheselandmarkeffortstheNationalInstitutesofHealth (NIH)CognitiveandEmotionalHealthProject(CEHP) wasofficiallylaunchedin2001Selectedexpertsfromseveral universitiesandtheNIHcriticallyanalyzedthescientific literaturetoidentifypossibleriskandprotectivefactorsfor maintainingcognitiveandemotionalhealthinadults6In recognitionoftheimportanceofthiseffortandasfurther testamenttotheincreasedvisibilitythatcognitivehealthis receivingCongressappropriatedfundsinfiscalyear2005to theCentersforDiseaseControlandPrevention(CDC)to addresscognitivehealthwithafocusonlifestyleissuesWith thissupportCDCformedapartnershipwiththeAlzheimerrsquos AssociationandisworkingcloselywiththeNationalInstitute onAgingtheAdministrationonAgingandotherpublicand privatesectororganizationsonaHealthyBrainInitiative
Thispartnership
bull FormedaSteeringCommitteemadeupofnationalexperts toprovideoverallguidanceandcoordinationfortheInitiative (AppendixA)
bull ConvenedaPublicHealthResearchWorkingGroup MeetinginMay2006onThe Healthy Brain and Our Aging PopulationTranslating Science to Public Health PracticeDuring
this2-dayinvitationalmeetingnationalexpertsreviewed researchinpublichealthpreventionrelatedtobrainhealth anddiscussedspecificrecommendationsforaddressingrisk andprotectivefactorsforpromotingcognitivehealthThey focusedonvascularriskfactorsandphysicalactivitybecause oftheirassociationwithcognitiveoutcomes
Thefindingsfromthisresearchmeetingprovidedafoundation andcommonframeofreferenceforthenextstepoftheHealthy BrainInitiativedevelopingstrategicpublichealthrecommenshydationsForthistaskthePartnershipformedworkgroups infourareasofpublichealthactionPreventionResearch CommunicationSurveillanceandPolicyEachworkgroup waschargedwithdraftingrecommendationsformovingthe nationforwardoverthenext3-5yearstowardthelong-term goalofmaintainingandimprovingthecognitivefunctionof adultsKeystakeholdersatthenationalstateandlocallevels thenrefinedtherecommendationsandselectedthoseof highestpriority(AppendixA)
TheNational Public Health Road Map to Maintaining Cognitive Healthreflectstheculminationofthis18-monthprocessAsa cornerstoneoftheInitiativeitoffersapathforhowwecan learnmoreaboutcognitivehealthandthenultimately
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoWearebeginningtotakethe nextstepsbuildingonthe researchcomingoutofNIH andothersandmovingwhat weknowoutintocommunity practiceThisiswherewecan makeadifferenceinthe everydaylivesofAmericansrdquo LyndaAAndersonPhD Healthy Aging Program Centers for Disease Control and Prevention
translatewhatwelearnintoreal-worldpracticetoimprove thehealthofallAmericans
TheauthorsoftheRoadMaprecognizethatinthecourse ofdailylifethedomainsofemotionalandcognitivehealth areinextricablylinkedandcannottrulybeseparatedFor thisRoadMaphoweverweassumethisdistinctionandfocus solelyoncognitivehealthOnlyrecentlyhavepublichealth expertiseandresourcesbeenrecognizedforaddressing cognitivehealthTheRoadMapreflectsacommitmentto bringtheareaofcognitivehealthldquouptoparrdquowithemotional healthastreatmentsandpreventivestrategiesbecomeavailable Itisthefirststepinasystematicprocessforbringingcognitive andemotionalhealthtogetherinamorecomprehensiveand coordinatedpublichealthapproach
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
A Sampling of Current Efforts
Pursuing Research on Factors Influencing Cognitive Health
TheNationalInstitutesofHealth(NIH)isfundingongoing researchtoclarifytherelationshipamongminimizingvascular riskfactorsexerciseotherlifestyleanddruginterventions andcognitivehealthstatusEpidemiologicstudiesare identifyinglikelyriskandprotectivefactorsthesearebeing testedinanimalstudieswhichalsocanhelpidentifythe mechanismsbywhichriskandprotectivefactorsmightwork Inordertoconfirmthattheencouraginginterventions identifiedinepidemiologyandanimalstudiescouldactually maintaincognitivehealthifappliedtohumansclinicaltrials mustbecarriedoutSomearealreadyinprogressbutothers arestillonlyintheplanningphaseNIHkeepsthepublicupshyto-dateonthecurrentstateofthesciencethroughoperation ofaWebsiteandanationalclearinghouse
Assessing Public Perceptions
Formativeresearchwithdiversegroupsisrequiredtohelp gainunderstandingonthepublicrsquosperceptionsaboutcognitive healthOnesucheffortiscurrentlyunderwaywiththesupport ofCDCTheHealthyAgingResearchNetworkwithinits largerPreventionResearchCentersProgram(PRC-HAN) conductspreventionresearchonavarietyofhealthissues involvingolderadultsWithinthePRC-HANmembersare collaboratingonaseriesoffocusgroupsdesignedtoidentify howdiversegroupsofolderadultsunderstandcognitive healthandwhatapproachestohealthpromotionanddisease preventionrelatedtobrainhealththepublicmayfindmost appealingThisprojecthasrecentlybeenexpandedtoexamine theperceptionsofcaregiversandhealthcareprovidersItwill provideimportantdatathatcanbeaddedtowhatisalready knownaboutcognitiveorbrainhealthidentifygapsin knowledgeaboutcognitivehealthandrelatedriskfactors anddeterminewhethersuchbeliefsvaryacrossgeographical distancesandbetweendiversepopulationsFinallythisworkis designedtoleadtothedevelopmentandtestingofashortset ofquestionsthatcanbeusedtoassessthepublicrsquosandpossibly providersrsquoperceptionsaboutcognitivehealthforinclusionin ongoingnationalattitudinalsurveys
0 |TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting Community Education Programs
TheAlzheimerrsquosAssociationhasrecentlylauncheda5-year community-baseddemonstrationprojecttopromoteabrainshyhealthylifestyleThecommunityinterventionisdesignedto affectknowledgeandattitudesamongAfricanAmericanbaby boomersrelatedtophysicalactivityandvascularriskfactors anditwillbeoverlaidwithothergeneralhealthbehaviors suchasdietsocialactivityandmentalactivityDuringthefirst phaseofthisprojecttheAlzheimerrsquosAssociationisleadinga comprehensiveinterventionplanninganddevelopmenteffort includingformativeresearchtoassesscurrentneedsand obstaclesforthetargetpopulationelicitingcommunityinput andparticipationandcreatingacomprehensivemultilevel communityinterventionwithrobustevaluationmechanisms tomeasuretheeffectivenessofthepublichealthprogramin itsnextphase
Developing Common Measures of Cognitive Decline for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativeto developunifiedandintegratedmethodsandmeasuresof cognitiveemotionalmotorandsensoryhealthforusein largecohortstudiesandclinicaltrialsResearchershave expressedtheneedforbriefassessmenttoolsthatcouldbe usedasaformofldquocommoncurrencyrdquoacrossdiversestudy designsandpopulationsThisinitiativewilltakeadvantage ofstate-of-the-artpsychometricresearchandnoveltesting methodstodevelopaninnovativeapproachtoneurological andbehavioralhealthmeasurementUltimatelyitishoped thatthisapproachwillrespondtotheneedsofresearchersin avarietyofsettingswithparticularemphasisonmeasuring outcomesinlargelongitudinalandepidemiologicstudiesand preventionorinterventiontrialsacrossthelifespanWith anavailabletoolboxofmeasuresyieldsfromlargeandvery expensivestudiescanbemaximizedbyallowingamuch largernumberofimportantresearchquestionsregarding neurologicalandbehavioralhealthtobestudiedByensuring thattheassessmentmethodsarecapableofcomparisonto existingandcompletedstudiesandcanincorporatefuture modificationsatrulyldquoeconomicrdquoandvaluablenational resourcefortheentireneurosciencecommunitywillresult
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
Why is it importantmdashand why now
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline
An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10
Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia
bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12
bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ldquoMostimportanttoourabilitytoliveourliveswellisthe combinationofmentalprocesseswecalllsquocognitionrsquoor lsquoknowingrsquoThiscombinationincludestheabilitytolearn newthingsintuitionjudgmentlanguageandremembering Havingaclearactivemindatanyageisimportantbutas wegetolderitcanmeanthedifferencebetweendependence andindependentlivingrdquo4
copewiththenormaldemandsoflivingproblemsaccessing healthcaresystemsgreatervulnerabilitytodiseaseinjury malnutritioncrimeandpossiblyabuseandeventuallyaloss ofindependenceThatlossofindependencebecomesaburden onfamiliesandsocietyastheindividualrequiresmoreintense careandofteninstitutionalizationInthelaterstagesthe cognitiveimpairmentassociatedwithdementiawillcreatetotal dependencyandAlzheimerrsquosdiseaseisnowrankedasthe 8th-leadingcauseofdeath5
Why prepare a Road Map
Bringingapublichealthperspectivetocognitivehealth requiresaninclusiveandstrategicapproachMuchimportant workhasalreadybeguninitiatedandsponsoredbyavariety oforganizationsandagenciesatnationalstateandlocallevels (seepages10-11forasamplingofcurrentefforts)
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
OneoftheselandmarkeffortstheNationalInstitutesofHealth (NIH)CognitiveandEmotionalHealthProject(CEHP) wasofficiallylaunchedin2001Selectedexpertsfromseveral universitiesandtheNIHcriticallyanalyzedthescientific literaturetoidentifypossibleriskandprotectivefactorsfor maintainingcognitiveandemotionalhealthinadults6In recognitionoftheimportanceofthiseffortandasfurther testamenttotheincreasedvisibilitythatcognitivehealthis receivingCongressappropriatedfundsinfiscalyear2005to theCentersforDiseaseControlandPrevention(CDC)to addresscognitivehealthwithafocusonlifestyleissuesWith thissupportCDCformedapartnershipwiththeAlzheimerrsquos AssociationandisworkingcloselywiththeNationalInstitute onAgingtheAdministrationonAgingandotherpublicand privatesectororganizationsonaHealthyBrainInitiative
Thispartnership
bull FormedaSteeringCommitteemadeupofnationalexperts toprovideoverallguidanceandcoordinationfortheInitiative (AppendixA)
bull ConvenedaPublicHealthResearchWorkingGroup MeetinginMay2006onThe Healthy Brain and Our Aging PopulationTranslating Science to Public Health PracticeDuring
this2-dayinvitationalmeetingnationalexpertsreviewed researchinpublichealthpreventionrelatedtobrainhealth anddiscussedspecificrecommendationsforaddressingrisk andprotectivefactorsforpromotingcognitivehealthThey focusedonvascularriskfactorsandphysicalactivitybecause oftheirassociationwithcognitiveoutcomes
Thefindingsfromthisresearchmeetingprovidedafoundation andcommonframeofreferenceforthenextstepoftheHealthy BrainInitiativedevelopingstrategicpublichealthrecommenshydationsForthistaskthePartnershipformedworkgroups infourareasofpublichealthactionPreventionResearch CommunicationSurveillanceandPolicyEachworkgroup waschargedwithdraftingrecommendationsformovingthe nationforwardoverthenext3-5yearstowardthelong-term goalofmaintainingandimprovingthecognitivefunctionof adultsKeystakeholdersatthenationalstateandlocallevels thenrefinedtherecommendationsandselectedthoseof highestpriority(AppendixA)
TheNational Public Health Road Map to Maintaining Cognitive Healthreflectstheculminationofthis18-monthprocessAsa cornerstoneoftheInitiativeitoffersapathforhowwecan learnmoreaboutcognitivehealthandthenultimately
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoWearebeginningtotakethe nextstepsbuildingonthe researchcomingoutofNIH andothersandmovingwhat weknowoutintocommunity practiceThisiswherewecan makeadifferenceinthe everydaylivesofAmericansrdquo LyndaAAndersonPhD Healthy Aging Program Centers for Disease Control and Prevention
translatewhatwelearnintoreal-worldpracticetoimprove thehealthofallAmericans
TheauthorsoftheRoadMaprecognizethatinthecourse ofdailylifethedomainsofemotionalandcognitivehealth areinextricablylinkedandcannottrulybeseparatedFor thisRoadMaphoweverweassumethisdistinctionandfocus solelyoncognitivehealthOnlyrecentlyhavepublichealth expertiseandresourcesbeenrecognizedforaddressing cognitivehealthTheRoadMapreflectsacommitmentto bringtheareaofcognitivehealthldquouptoparrdquowithemotional healthastreatmentsandpreventivestrategiesbecomeavailable Itisthefirststepinasystematicprocessforbringingcognitive andemotionalhealthtogetherinamorecomprehensiveand coordinatedpublichealthapproach
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
A Sampling of Current Efforts
Pursuing Research on Factors Influencing Cognitive Health
TheNationalInstitutesofHealth(NIH)isfundingongoing researchtoclarifytherelationshipamongminimizingvascular riskfactorsexerciseotherlifestyleanddruginterventions andcognitivehealthstatusEpidemiologicstudiesare identifyinglikelyriskandprotectivefactorsthesearebeing testedinanimalstudieswhichalsocanhelpidentifythe mechanismsbywhichriskandprotectivefactorsmightwork Inordertoconfirmthattheencouraginginterventions identifiedinepidemiologyandanimalstudiescouldactually maintaincognitivehealthifappliedtohumansclinicaltrials mustbecarriedoutSomearealreadyinprogressbutothers arestillonlyintheplanningphaseNIHkeepsthepublicupshyto-dateonthecurrentstateofthesciencethroughoperation ofaWebsiteandanationalclearinghouse
Assessing Public Perceptions
Formativeresearchwithdiversegroupsisrequiredtohelp gainunderstandingonthepublicrsquosperceptionsaboutcognitive healthOnesucheffortiscurrentlyunderwaywiththesupport ofCDCTheHealthyAgingResearchNetworkwithinits largerPreventionResearchCentersProgram(PRC-HAN) conductspreventionresearchonavarietyofhealthissues involvingolderadultsWithinthePRC-HANmembersare collaboratingonaseriesoffocusgroupsdesignedtoidentify howdiversegroupsofolderadultsunderstandcognitive healthandwhatapproachestohealthpromotionanddisease preventionrelatedtobrainhealththepublicmayfindmost appealingThisprojecthasrecentlybeenexpandedtoexamine theperceptionsofcaregiversandhealthcareprovidersItwill provideimportantdatathatcanbeaddedtowhatisalready knownaboutcognitiveorbrainhealthidentifygapsin knowledgeaboutcognitivehealthandrelatedriskfactors anddeterminewhethersuchbeliefsvaryacrossgeographical distancesandbetweendiversepopulationsFinallythisworkis designedtoleadtothedevelopmentandtestingofashortset ofquestionsthatcanbeusedtoassessthepublicrsquosandpossibly providersrsquoperceptionsaboutcognitivehealthforinclusionin ongoingnationalattitudinalsurveys
0 |TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting Community Education Programs
TheAlzheimerrsquosAssociationhasrecentlylauncheda5-year community-baseddemonstrationprojecttopromoteabrainshyhealthylifestyleThecommunityinterventionisdesignedto affectknowledgeandattitudesamongAfricanAmericanbaby boomersrelatedtophysicalactivityandvascularriskfactors anditwillbeoverlaidwithothergeneralhealthbehaviors suchasdietsocialactivityandmentalactivityDuringthefirst phaseofthisprojecttheAlzheimerrsquosAssociationisleadinga comprehensiveinterventionplanninganddevelopmenteffort includingformativeresearchtoassesscurrentneedsand obstaclesforthetargetpopulationelicitingcommunityinput andparticipationandcreatingacomprehensivemultilevel communityinterventionwithrobustevaluationmechanisms tomeasuretheeffectivenessofthepublichealthprogramin itsnextphase
Developing Common Measures of Cognitive Decline for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativeto developunifiedandintegratedmethodsandmeasuresof cognitiveemotionalmotorandsensoryhealthforusein largecohortstudiesandclinicaltrialsResearchershave expressedtheneedforbriefassessmenttoolsthatcouldbe usedasaformofldquocommoncurrencyrdquoacrossdiversestudy designsandpopulationsThisinitiativewilltakeadvantage ofstate-of-the-artpsychometricresearchandnoveltesting methodstodevelopaninnovativeapproachtoneurological andbehavioralhealthmeasurementUltimatelyitishoped thatthisapproachwillrespondtotheneedsofresearchersin avarietyofsettingswithparticularemphasisonmeasuring outcomesinlargelongitudinalandepidemiologicstudiesand preventionorinterventiontrialsacrossthelifespanWith anavailabletoolboxofmeasuresyieldsfromlargeandvery expensivestudiescanbemaximizedbyallowingamuch largernumberofimportantresearchquestionsregarding neurologicalandbehavioralhealthtobestudiedByensuring thattheassessmentmethodsarecapableofcomparisonto existingandcompletedstudiesandcanincorporatefuture modificationsatrulyldquoeconomicrdquoandvaluablenational resourcefortheentireneurosciencecommunitywillresult
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
Why is it importantmdashand why now
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline
An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10
Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia
bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12
bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Background
OneoftheselandmarkeffortstheNationalInstitutesofHealth (NIH)CognitiveandEmotionalHealthProject(CEHP) wasofficiallylaunchedin2001Selectedexpertsfromseveral universitiesandtheNIHcriticallyanalyzedthescientific literaturetoidentifypossibleriskandprotectivefactorsfor maintainingcognitiveandemotionalhealthinadults6In recognitionoftheimportanceofthiseffortandasfurther testamenttotheincreasedvisibilitythatcognitivehealthis receivingCongressappropriatedfundsinfiscalyear2005to theCentersforDiseaseControlandPrevention(CDC)to addresscognitivehealthwithafocusonlifestyleissuesWith thissupportCDCformedapartnershipwiththeAlzheimerrsquos AssociationandisworkingcloselywiththeNationalInstitute onAgingtheAdministrationonAgingandotherpublicand privatesectororganizationsonaHealthyBrainInitiative
Thispartnership
bull FormedaSteeringCommitteemadeupofnationalexperts toprovideoverallguidanceandcoordinationfortheInitiative (AppendixA)
bull ConvenedaPublicHealthResearchWorkingGroup MeetinginMay2006onThe Healthy Brain and Our Aging PopulationTranslating Science to Public Health PracticeDuring
this2-dayinvitationalmeetingnationalexpertsreviewed researchinpublichealthpreventionrelatedtobrainhealth anddiscussedspecificrecommendationsforaddressingrisk andprotectivefactorsforpromotingcognitivehealthThey focusedonvascularriskfactorsandphysicalactivitybecause oftheirassociationwithcognitiveoutcomes
Thefindingsfromthisresearchmeetingprovidedafoundation andcommonframeofreferenceforthenextstepoftheHealthy BrainInitiativedevelopingstrategicpublichealthrecommenshydationsForthistaskthePartnershipformedworkgroups infourareasofpublichealthactionPreventionResearch CommunicationSurveillanceandPolicyEachworkgroup waschargedwithdraftingrecommendationsformovingthe nationforwardoverthenext3-5yearstowardthelong-term goalofmaintainingandimprovingthecognitivefunctionof adultsKeystakeholdersatthenationalstateandlocallevels thenrefinedtherecommendationsandselectedthoseof highestpriority(AppendixA)
TheNational Public Health Road Map to Maintaining Cognitive Healthreflectstheculminationofthis18-monthprocessAsa cornerstoneoftheInitiativeitoffersapathforhowwecan learnmoreaboutcognitivehealthandthenultimately
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoWearebeginningtotakethe nextstepsbuildingonthe researchcomingoutofNIH andothersandmovingwhat weknowoutintocommunity practiceThisiswherewecan makeadifferenceinthe everydaylivesofAmericansrdquo LyndaAAndersonPhD Healthy Aging Program Centers for Disease Control and Prevention
translatewhatwelearnintoreal-worldpracticetoimprove thehealthofallAmericans
TheauthorsoftheRoadMaprecognizethatinthecourse ofdailylifethedomainsofemotionalandcognitivehealth areinextricablylinkedandcannottrulybeseparatedFor thisRoadMaphoweverweassumethisdistinctionandfocus solelyoncognitivehealthOnlyrecentlyhavepublichealth expertiseandresourcesbeenrecognizedforaddressing cognitivehealthTheRoadMapreflectsacommitmentto bringtheareaofcognitivehealthldquouptoparrdquowithemotional healthastreatmentsandpreventivestrategiesbecomeavailable Itisthefirststepinasystematicprocessforbringingcognitive andemotionalhealthtogetherinamorecomprehensiveand coordinatedpublichealthapproach
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
A Sampling of Current Efforts
Pursuing Research on Factors Influencing Cognitive Health
TheNationalInstitutesofHealth(NIH)isfundingongoing researchtoclarifytherelationshipamongminimizingvascular riskfactorsexerciseotherlifestyleanddruginterventions andcognitivehealthstatusEpidemiologicstudiesare identifyinglikelyriskandprotectivefactorsthesearebeing testedinanimalstudieswhichalsocanhelpidentifythe mechanismsbywhichriskandprotectivefactorsmightwork Inordertoconfirmthattheencouraginginterventions identifiedinepidemiologyandanimalstudiescouldactually maintaincognitivehealthifappliedtohumansclinicaltrials mustbecarriedoutSomearealreadyinprogressbutothers arestillonlyintheplanningphaseNIHkeepsthepublicupshyto-dateonthecurrentstateofthesciencethroughoperation ofaWebsiteandanationalclearinghouse
Assessing Public Perceptions
Formativeresearchwithdiversegroupsisrequiredtohelp gainunderstandingonthepublicrsquosperceptionsaboutcognitive healthOnesucheffortiscurrentlyunderwaywiththesupport ofCDCTheHealthyAgingResearchNetworkwithinits largerPreventionResearchCentersProgram(PRC-HAN) conductspreventionresearchonavarietyofhealthissues involvingolderadultsWithinthePRC-HANmembersare collaboratingonaseriesoffocusgroupsdesignedtoidentify howdiversegroupsofolderadultsunderstandcognitive healthandwhatapproachestohealthpromotionanddisease preventionrelatedtobrainhealththepublicmayfindmost appealingThisprojecthasrecentlybeenexpandedtoexamine theperceptionsofcaregiversandhealthcareprovidersItwill provideimportantdatathatcanbeaddedtowhatisalready knownaboutcognitiveorbrainhealthidentifygapsin knowledgeaboutcognitivehealthandrelatedriskfactors anddeterminewhethersuchbeliefsvaryacrossgeographical distancesandbetweendiversepopulationsFinallythisworkis designedtoleadtothedevelopmentandtestingofashortset ofquestionsthatcanbeusedtoassessthepublicrsquosandpossibly providersrsquoperceptionsaboutcognitivehealthforinclusionin ongoingnationalattitudinalsurveys
0 |TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting Community Education Programs
TheAlzheimerrsquosAssociationhasrecentlylauncheda5-year community-baseddemonstrationprojecttopromoteabrainshyhealthylifestyleThecommunityinterventionisdesignedto affectknowledgeandattitudesamongAfricanAmericanbaby boomersrelatedtophysicalactivityandvascularriskfactors anditwillbeoverlaidwithothergeneralhealthbehaviors suchasdietsocialactivityandmentalactivityDuringthefirst phaseofthisprojecttheAlzheimerrsquosAssociationisleadinga comprehensiveinterventionplanninganddevelopmenteffort includingformativeresearchtoassesscurrentneedsand obstaclesforthetargetpopulationelicitingcommunityinput andparticipationandcreatingacomprehensivemultilevel communityinterventionwithrobustevaluationmechanisms tomeasuretheeffectivenessofthepublichealthprogramin itsnextphase
Developing Common Measures of Cognitive Decline for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativeto developunifiedandintegratedmethodsandmeasuresof cognitiveemotionalmotorandsensoryhealthforusein largecohortstudiesandclinicaltrialsResearchershave expressedtheneedforbriefassessmenttoolsthatcouldbe usedasaformofldquocommoncurrencyrdquoacrossdiversestudy designsandpopulationsThisinitiativewilltakeadvantage ofstate-of-the-artpsychometricresearchandnoveltesting methodstodevelopaninnovativeapproachtoneurological andbehavioralhealthmeasurementUltimatelyitishoped thatthisapproachwillrespondtotheneedsofresearchersin avarietyofsettingswithparticularemphasisonmeasuring outcomesinlargelongitudinalandepidemiologicstudiesand preventionorinterventiontrialsacrossthelifespanWith anavailabletoolboxofmeasuresyieldsfromlargeandvery expensivestudiescanbemaximizedbyallowingamuch largernumberofimportantresearchquestionsregarding neurologicalandbehavioralhealthtobestudiedByensuring thattheassessmentmethodsarecapableofcomparisonto existingandcompletedstudiesandcanincorporatefuture modificationsatrulyldquoeconomicrdquoandvaluablenational resourcefortheentireneurosciencecommunitywillresult
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
Why is it importantmdashand why now
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline
An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10
Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia
bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12
bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ldquoWearebeginningtotakethe nextstepsbuildingonthe researchcomingoutofNIH andothersandmovingwhat weknowoutintocommunity practiceThisiswherewecan makeadifferenceinthe everydaylivesofAmericansrdquo LyndaAAndersonPhD Healthy Aging Program Centers for Disease Control and Prevention
translatewhatwelearnintoreal-worldpracticetoimprove thehealthofallAmericans
TheauthorsoftheRoadMaprecognizethatinthecourse ofdailylifethedomainsofemotionalandcognitivehealth areinextricablylinkedandcannottrulybeseparatedFor thisRoadMaphoweverweassumethisdistinctionandfocus solelyoncognitivehealthOnlyrecentlyhavepublichealth expertiseandresourcesbeenrecognizedforaddressing cognitivehealthTheRoadMapreflectsacommitmentto bringtheareaofcognitivehealthldquouptoparrdquowithemotional healthastreatmentsandpreventivestrategiesbecomeavailable Itisthefirststepinasystematicprocessforbringingcognitive andemotionalhealthtogetherinamorecomprehensiveand coordinatedpublichealthapproach
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
A Sampling of Current Efforts
Pursuing Research on Factors Influencing Cognitive Health
TheNationalInstitutesofHealth(NIH)isfundingongoing researchtoclarifytherelationshipamongminimizingvascular riskfactorsexerciseotherlifestyleanddruginterventions andcognitivehealthstatusEpidemiologicstudiesare identifyinglikelyriskandprotectivefactorsthesearebeing testedinanimalstudieswhichalsocanhelpidentifythe mechanismsbywhichriskandprotectivefactorsmightwork Inordertoconfirmthattheencouraginginterventions identifiedinepidemiologyandanimalstudiescouldactually maintaincognitivehealthifappliedtohumansclinicaltrials mustbecarriedoutSomearealreadyinprogressbutothers arestillonlyintheplanningphaseNIHkeepsthepublicupshyto-dateonthecurrentstateofthesciencethroughoperation ofaWebsiteandanationalclearinghouse
Assessing Public Perceptions
Formativeresearchwithdiversegroupsisrequiredtohelp gainunderstandingonthepublicrsquosperceptionsaboutcognitive healthOnesucheffortiscurrentlyunderwaywiththesupport ofCDCTheHealthyAgingResearchNetworkwithinits largerPreventionResearchCentersProgram(PRC-HAN) conductspreventionresearchonavarietyofhealthissues involvingolderadultsWithinthePRC-HANmembersare collaboratingonaseriesoffocusgroupsdesignedtoidentify howdiversegroupsofolderadultsunderstandcognitive healthandwhatapproachestohealthpromotionanddisease preventionrelatedtobrainhealththepublicmayfindmost appealingThisprojecthasrecentlybeenexpandedtoexamine theperceptionsofcaregiversandhealthcareprovidersItwill provideimportantdatathatcanbeaddedtowhatisalready knownaboutcognitiveorbrainhealthidentifygapsin knowledgeaboutcognitivehealthandrelatedriskfactors anddeterminewhethersuchbeliefsvaryacrossgeographical distancesandbetweendiversepopulationsFinallythisworkis designedtoleadtothedevelopmentandtestingofashortset ofquestionsthatcanbeusedtoassessthepublicrsquosandpossibly providersrsquoperceptionsaboutcognitivehealthforinclusionin ongoingnationalattitudinalsurveys
0 |TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting Community Education Programs
TheAlzheimerrsquosAssociationhasrecentlylauncheda5-year community-baseddemonstrationprojecttopromoteabrainshyhealthylifestyleThecommunityinterventionisdesignedto affectknowledgeandattitudesamongAfricanAmericanbaby boomersrelatedtophysicalactivityandvascularriskfactors anditwillbeoverlaidwithothergeneralhealthbehaviors suchasdietsocialactivityandmentalactivityDuringthefirst phaseofthisprojecttheAlzheimerrsquosAssociationisleadinga comprehensiveinterventionplanninganddevelopmenteffort includingformativeresearchtoassesscurrentneedsand obstaclesforthetargetpopulationelicitingcommunityinput andparticipationandcreatingacomprehensivemultilevel communityinterventionwithrobustevaluationmechanisms tomeasuretheeffectivenessofthepublichealthprogramin itsnextphase
Developing Common Measures of Cognitive Decline for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativeto developunifiedandintegratedmethodsandmeasuresof cognitiveemotionalmotorandsensoryhealthforusein largecohortstudiesandclinicaltrialsResearchershave expressedtheneedforbriefassessmenttoolsthatcouldbe usedasaformofldquocommoncurrencyrdquoacrossdiversestudy designsandpopulationsThisinitiativewilltakeadvantage ofstate-of-the-artpsychometricresearchandnoveltesting methodstodevelopaninnovativeapproachtoneurological andbehavioralhealthmeasurementUltimatelyitishoped thatthisapproachwillrespondtotheneedsofresearchersin avarietyofsettingswithparticularemphasisonmeasuring outcomesinlargelongitudinalandepidemiologicstudiesand preventionorinterventiontrialsacrossthelifespanWith anavailabletoolboxofmeasuresyieldsfromlargeandvery expensivestudiescanbemaximizedbyallowingamuch largernumberofimportantresearchquestionsregarding neurologicalandbehavioralhealthtobestudiedByensuring thattheassessmentmethodsarecapableofcomparisonto existingandcompletedstudiesandcanincorporatefuture modificationsatrulyldquoeconomicrdquoandvaluablenational resourcefortheentireneurosciencecommunitywillresult
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
Why is it importantmdashand why now
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline
An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10
Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia
bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12
bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Background
A Sampling of Current Efforts
Pursuing Research on Factors Influencing Cognitive Health
TheNationalInstitutesofHealth(NIH)isfundingongoing researchtoclarifytherelationshipamongminimizingvascular riskfactorsexerciseotherlifestyleanddruginterventions andcognitivehealthstatusEpidemiologicstudiesare identifyinglikelyriskandprotectivefactorsthesearebeing testedinanimalstudieswhichalsocanhelpidentifythe mechanismsbywhichriskandprotectivefactorsmightwork Inordertoconfirmthattheencouraginginterventions identifiedinepidemiologyandanimalstudiescouldactually maintaincognitivehealthifappliedtohumansclinicaltrials mustbecarriedoutSomearealreadyinprogressbutothers arestillonlyintheplanningphaseNIHkeepsthepublicupshyto-dateonthecurrentstateofthesciencethroughoperation ofaWebsiteandanationalclearinghouse
Assessing Public Perceptions
Formativeresearchwithdiversegroupsisrequiredtohelp gainunderstandingonthepublicrsquosperceptionsaboutcognitive healthOnesucheffortiscurrentlyunderwaywiththesupport ofCDCTheHealthyAgingResearchNetworkwithinits largerPreventionResearchCentersProgram(PRC-HAN) conductspreventionresearchonavarietyofhealthissues involvingolderadultsWithinthePRC-HANmembersare collaboratingonaseriesoffocusgroupsdesignedtoidentify howdiversegroupsofolderadultsunderstandcognitive healthandwhatapproachestohealthpromotionanddisease preventionrelatedtobrainhealththepublicmayfindmost appealingThisprojecthasrecentlybeenexpandedtoexamine theperceptionsofcaregiversandhealthcareprovidersItwill provideimportantdatathatcanbeaddedtowhatisalready knownaboutcognitiveorbrainhealthidentifygapsin knowledgeaboutcognitivehealthandrelatedriskfactors anddeterminewhethersuchbeliefsvaryacrossgeographical distancesandbetweendiversepopulationsFinallythisworkis designedtoleadtothedevelopmentandtestingofashortset ofquestionsthatcanbeusedtoassessthepublicrsquosandpossibly providersrsquoperceptionsaboutcognitivehealthforinclusionin ongoingnationalattitudinalsurveys
0 |TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting Community Education Programs
TheAlzheimerrsquosAssociationhasrecentlylauncheda5-year community-baseddemonstrationprojecttopromoteabrainshyhealthylifestyleThecommunityinterventionisdesignedto affectknowledgeandattitudesamongAfricanAmericanbaby boomersrelatedtophysicalactivityandvascularriskfactors anditwillbeoverlaidwithothergeneralhealthbehaviors suchasdietsocialactivityandmentalactivityDuringthefirst phaseofthisprojecttheAlzheimerrsquosAssociationisleadinga comprehensiveinterventionplanninganddevelopmenteffort includingformativeresearchtoassesscurrentneedsand obstaclesforthetargetpopulationelicitingcommunityinput andparticipationandcreatingacomprehensivemultilevel communityinterventionwithrobustevaluationmechanisms tomeasuretheeffectivenessofthepublichealthprogramin itsnextphase
Developing Common Measures of Cognitive Decline for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativeto developunifiedandintegratedmethodsandmeasuresof cognitiveemotionalmotorandsensoryhealthforusein largecohortstudiesandclinicaltrialsResearchershave expressedtheneedforbriefassessmenttoolsthatcouldbe usedasaformofldquocommoncurrencyrdquoacrossdiversestudy designsandpopulationsThisinitiativewilltakeadvantage ofstate-of-the-artpsychometricresearchandnoveltesting methodstodevelopaninnovativeapproachtoneurological andbehavioralhealthmeasurementUltimatelyitishoped thatthisapproachwillrespondtotheneedsofresearchersin avarietyofsettingswithparticularemphasisonmeasuring outcomesinlargelongitudinalandepidemiologicstudiesand preventionorinterventiontrialsacrossthelifespanWith anavailabletoolboxofmeasuresyieldsfromlargeandvery expensivestudiescanbemaximizedbyallowingamuch largernumberofimportantresearchquestionsregarding neurologicalandbehavioralhealthtobestudiedByensuring thattheassessmentmethodsarecapableofcomparisonto existingandcompletedstudiesandcanincorporatefuture modificationsatrulyldquoeconomicrdquoandvaluablenational resourcefortheentireneurosciencecommunitywillresult
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
Why is it importantmdashand why now
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline
An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10
Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia
bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12
bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Conducting Community Education Programs
TheAlzheimerrsquosAssociationhasrecentlylauncheda5-year community-baseddemonstrationprojecttopromoteabrainshyhealthylifestyleThecommunityinterventionisdesignedto affectknowledgeandattitudesamongAfricanAmericanbaby boomersrelatedtophysicalactivityandvascularriskfactors anditwillbeoverlaidwithothergeneralhealthbehaviors suchasdietsocialactivityandmentalactivityDuringthefirst phaseofthisprojecttheAlzheimerrsquosAssociationisleadinga comprehensiveinterventionplanninganddevelopmenteffort includingformativeresearchtoassesscurrentneedsand obstaclesforthetargetpopulationelicitingcommunityinput andparticipationandcreatingacomprehensivemultilevel communityinterventionwithrobustevaluationmechanisms tomeasuretheeffectivenessofthepublichealthprogramin itsnextphase
Developing Common Measures of Cognitive Decline for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativeto developunifiedandintegratedmethodsandmeasuresof cognitiveemotionalmotorandsensoryhealthforusein largecohortstudiesandclinicaltrialsResearchershave expressedtheneedforbriefassessmenttoolsthatcouldbe usedasaformofldquocommoncurrencyrdquoacrossdiversestudy designsandpopulationsThisinitiativewilltakeadvantage ofstate-of-the-artpsychometricresearchandnoveltesting methodstodevelopaninnovativeapproachtoneurological andbehavioralhealthmeasurementUltimatelyitishoped thatthisapproachwillrespondtotheneedsofresearchersin avarietyofsettingswithparticularemphasisonmeasuring outcomesinlargelongitudinalandepidemiologicstudiesand preventionorinterventiontrialsacrossthelifespanWith anavailabletoolboxofmeasuresyieldsfromlargeandvery expensivestudiescanbemaximizedbyallowingamuch largernumberofimportantresearchquestionsregarding neurologicalandbehavioralhealthtobestudiedByensuring thattheassessmentmethodsarecapableofcomparisonto existingandcompletedstudiesandcanincorporatefuture modificationsatrulyldquoeconomicrdquoandvaluablenational resourcefortheentireneurosciencecommunitywillresult
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
Why is it importantmdashand why now
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline
An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10
Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia
bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12
bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Background
Why is it importantmdashand why now
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltimegiventhedramaticagingof theUSpopulationthegrowingscientificinterestinthe roleoflifestylestrategiesinmaintainingcognitivefunction andincreasingawarenessofthesignificanthealthsocial andeconomicburdensassociatedwithcognitivedecline
An aging population AgeisariskfactorforcognitivedeclineIn2004onein everyeightAmericansmdash363millionmdashwereaged65years orolderBy2030thisnumberisexpectedtonearlydouble to715millionAtthattime20ofthepopulationwillbe inthisagegroup7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthe lossofcognitivehealthtodiseaseordisability8aconcernthat seemstoincreasewithageMostolderadultslookforwardto havingalonglifeandyettheirgreatestworriesaboutliving toage75revolvearoundmemoryloss9Accordingtoarecent surveyadultsaremorethantwiceaslikelytofearlosingtheir mentalcapacity(62)astheirphysicalability(29)10
Increasing burden from cognitive decline IntheUnitedStatesthesocietalburdenofcognitive impairmenthasbeenexpressedmainlyintermsofprevalence incidenceandmortalityfordementiagenerallyorfor AlzheimerrsquosdiseaseinparticularMorerecentlyprevalence statisticsforldquomildcognitiveimpairmentrdquoorldquocognitive impairmentnodementiardquohavealsoappearedCognitive impairmentnodementiareferstoalevelofcognitive impairmentthatismoreseriousthanage-relatedcognitive impairmentbutitisnotassevereasAlzheimerrsquosdiseaseor otherformsofdementia
bull Alzheimerrsquosdiseasehasbeeninthetoptenleadingcauses ofdeathsincethe20thcentury11Notablythemortalityrates forAlzheimerrsquosdiseaseareontherisemdashincontrasttothe ratesforheartdiseaseandcancerwhicharecontinuing todecline12
bull Anestimated45millionAmericanshaveAlzheimerrsquos diseaseThatnumberhasdoubledsince1980andis expectedtobeashighas16millionby205013
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ldquoThenewsciencehasshiftedthe focustotheideathatthereis valueinapublichealthstrategy ofgettingpeopletothinkabout theirbrainandhowtheymight altertheirbehaviortokeep theirbrainhealthyrdquo StephenMcConnellPhD Alzheimerrsquos Association
bull StudiesfromtheUnitedStatesandCanadahavesuggested thatmildcognitiveimpairmentorcognitiveimpairment nodementiamaybeaproblemfor16-25oftheelderly population(65andolder)141516
bull In2005MedicareandMedicaidspent$91billionand $21billionrespectivelyforpersonswithAlzheimerrsquosdisease17 Accordingtoa2004reportthatanalyzedMedicareclaims dataolderbeneficiarieswithdementiacostMedicarethree timesmorethanotherolderbeneficiaries18Basedoncurrent estimatesthesecostswilldoubleevery10years19
Caregiver burden Maintainingcognitivehealthcanmeanthedifference betweenlivingindependentlyorfacingtheneedforfamily orinstitutionalcareTheburdenofcognitivedeclineon caregiversisenormousThenumberofcaregiversinthe UnitedStatesin2003wasestimatedtobe444million20and thisnumberisexpectedtorisedramaticallywiththeagingof
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Background
thepopulationThecostsofunpaidinformalcareprovidedby familieshavebeenshowntoaccountforalargeproportionof thecostsoftreatingdementiaandtheyincreasesharplyasthe patientrsquoscognitiveimpairmentworsens21Therearealso physicalandmentalcostsassociatedwithcaregivinginone studynearly43ofthefamilymembersprovidingcareto relativeswithdementiahadclinicallysignificantlevelsof depressionduringthelastfewmonthsofthepatientrsquoslife22 Numerousfactorsmakeprovidingcareforpersonswith severedementiaemotionallyandphysicallychallenginga betterunderstandingofthesefactorswillaidinthedesignof strategiesthatsupportthehealthandwell-beingofcaregivers
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeof irreversiblementaldeclineandthatdementiaisuniversal andinevitableThesemythspersistseventhoughrecent researchhasshownthatinthehealthyagingbrainnew synapsescontinuetoformandnervecellscanregenerate23
YetthereareemergingsignsthatAmericanslooktothe futurewithhopeBasedonseveralsurveysmenandwomen inthiscountryarewillingtotakeimportantstepstoimprove theircognitivehealth
bull Nearly9of10peoplereportedthattheythoughtitis possibletoimprovecognitivefitness24
bull Sixof10statedthattheyfelttheyshouldhavetheir cognitivehealthcheckedroutinelymuchlikearegular physicalcheckup25
bull Morethan8of10(84)reportedthattheytooksome timenearlyeverydaytoengageinactivitiesthatmaybe associatedwithimprovedcognitivehealthengagingin artorcreativeprojectsreadingkeepingphysicallyactive playinggamesordoingpuzzlesworkingorspending timewithfamilyandfriends26
bull Overhalfanticipatedamajormedicalbreakthroughin discoveringacureforAlzheimerrsquosdiseasewithinthenext 20years27
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Giventhetremendousburdensdescribedtheirimpactand thedevelopingsciencepublichealthshouldstepforwardto addresscognitivehealthThepotentialcontributiontoquality oflifethepositiveimpactoncaregiversandtheanticipated savingsinthecostsofhealthcareandotherserviceswould beconsiderable28293031
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
I background
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
State of Knowledge What do we know
InMay2006CDCandtheAlzheimerrsquosAssociationinvited nationalexpertstoreviewresearchonpublichealth preventionrelatedtocognitivehealthandtoidentifyspecific recommendationsforaddressingriskfactorsthatpromoteand protectcognitivehealthDuringthismeetingparticipants examinedthecurrentstateofscienceconcerningmajorrisk
factorsincludinga)riskfactorsforvasculardiseaseand b)physicalinactivityandtheylookedatcurrentmodels formovingscienceintopublichealthpracticeParticipants focusedonthesefactorsbecauseoftheirassociationwith cognitiveoutcomes32Theyconcludedthatresearchsuggests thefollowingfactorsmaybeassociatedwiththemaintenance ofcognitivehealth1)preventingorcontrollinghighblood
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
StateofKnowledge
pressurecholesteroldiabetesoverweightandobesity 2)preventingorstoppingsmokingand3)being physicallyactive33
Severalspecificobservationswerenotedbymeeting participantsregardingtheassociationsbetweenvascular riskfactorsandphysicalinactivityandcognition
bull Evidenceexiststoindicatethatcumulativerisks forvasculardiseaseincreasetheriskforstrokeand cognitivedecline
bull Sufficientevidencealsoexiststosupporttheassociation betweenvascularhealthandcognitivehealthalthough clinicaltrialsarenecessarytoestablishtheeffectivenessof interventionstargetedtovascularriskfactors
bull Itisimportanttoemphasizethatcontrollingvascularrisk factorsisassociatedwithreductioninanindividualrsquosriskof cognitiveproblemsbutcurrentsciencedoesnotsupportthe relationshipbetweencontrollingvascularriskfactorsand improvedcognitivefunction
bull Growingevidenceexiststhatphysicalactivitymaymaintain orimprovesomeaspectsofcognitivefunctionintheshort termbutfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(eg theamountofphysicalactivity)
bull Strongevidenceexiststosupporttherelationshipbetween physicalactivityandemotionalwell-being
WhilenotaspecificfocusoftheMayresearchmeeting additionalfactorsthatmaybeassociatedwithmaintaining cognitivefunctionincludesocialengagementaldquoheart-healthyrdquo dietandemotionalsupportsInadditionhigherhouseholdand communitysocioeconomiclevelsinearlylifeareassociated withhigherlevelsofcognitioninlatelifebutnotwiththerisk ofAlzheimerrsquosdiseaseorrateofcognitivedecline34
What gaps exist
Eachnewdiscoveryinmaintainingcognitivehealthraisesa hostofimportantquestionsSomeofthemorepressingissues arethefollowing
bull Howdowepromotetheimportanceofcognitivehealth issuestokeyconstituenciesandstakeholders
bull Whatarethepublicrsquosperspectivesonlifestylebehaviors choicesandattitudesconcerningcognitivehealthandthe burdenofcognitivedeclineWhatdoweviewasthebenefits
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ldquoAllthethingsthatweknow arebadforyourheartturn outtobebadforyourbrainrdquo MarilynSAlbertPhD Johns Hopkins Medical Institutions
andbarriersofmodifyingpersonallifestyletoreducetherisks associatedwithcognitivedecline
bull Whatistheroleofpopulation-basedsurveillanceandthe appropriatesurveillancesystemstoassesscognitivedecline
bull Whatclinicaltrialsandotherresearchareneededto determinethelong-termoutcomesoflifestyleinterventions onparticularcognitivefunctions
bull Howdowelinkscientificallyvalidmessagesaboutriskof cognitivedeclinetocurrentpublichealthmessagesfor effortsinprimaryprevention
bull Whataretheeffectsofmodifyingmultipleriskfactors onminimizingcognitivedeclineorimproving cognitivefunction
How can public health contribute
Publichealthwasfirstdefinedin1926asldquothescienceandartof preventingdiseaseprolonginglifeandpromotinghealthand efficiencythroughorganizedcommunityeffortrdquo35That definitionhasremainedintactforover80yearswitharecent reiterationofpublichealthrsquosmissionasldquoassuringconditionsin whichpeoplecanbehealthyrdquo36
Organizedpublichealtheffortsoverthepast100yearshave yieldedremarkableachievementsTenconsideredtobeamong thegreatest37areintheareasof
bull Vaccination bull Motor-vehiclesafety bull Saferworkplaces bull Controlofinfectiousdiseases bull Declineindeathsfromcoronaryheartdisease andstroke
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
StateofKnowledge
bull Saferandhealthierfoods bull Healthiermothersandbabies bull Familyplanning bull Fluoridationofdrinkingwater bull Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined coordinatedeffortstoapplythreecorepublichealth functionsassessmentpolicydevelopmentandassurance
Assessmentcallsforregularlyandsystematicallycollecting analyzingandsharinginformationonthehealthofa communitySuchinformationhelpstodescribeand understandacommunityrsquoshealthstatusandneedsAssessment activitiesmightinvolveinvestigatingadversehealtheffects andhealthhazardstoidentifythemagnitudeofahealth problemitslocationtrendsovertimeandpopulationsat riskTheymayalsoldquodigdeeperrdquotoanalyzedeterminantsof identifiedhealthproblemssoastoilluminateetiologicand contributingfactorsthatplacecertainpopulationgroupsat riskforadversehealthoutcomes
Policy developmententailspromotionofpublichealth policiesthataregroundedinscience-baseddecisionmaking Bytakingtheleadinpolicydevelopmentpublichealthserves
asanadvocatebuildsconstituenciesandidentifiesresources inacommunityasitgeneratessupportiveandcollaborative relationshipswithpublicandprivateagenciesAnothercritical policyactivityinvolveshelpingcommunitiessetpriorities amonghealthneedsbasedonthesizeandseriousnessofthe healthproblemsandtheacceptabilityeconomicfeasibilityand effectivenessofinterventionsthecommunitycanthendevelop plansandpoliciestoaddressthosepriorities
Assuranceistheguaranteethatservicesneededtoachieve agreed-upongoalsareactuallyprovidedItispursuedby encouragingtheactionsofothers(publicorprivate)requiring actionthroughregulationorbyprovidingservicesdirectly Thisthirdcorepublichealthfunctionencompassesmanaging resourcesanddevelopingorganizationalstructuresimplementing programsforpriorityhealthneedsandevaluatingandproviding qualityassurancetoensurethatprogramsareconsistentwith plansandpoliciesmdashorthatneededcorrectiveactionsare takenpromptlyInadditionassuranceactivitieshelptoinform andeducatethepubliconhealthissuesofconcernpromote awarenessofpublichealthservicesandpromotehealth educationinitiativesthatcontributetoindividualorcollective changesinhealthknowledgeattitudesandpracticesthat makeforahealthiercommunity
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ldquoIfyoucouldgivepeople informationandtoolsthat woulddelaytheonsetof cognitiveimpairmentby afewyearsyouwouldbe doingmuchtoimprove individualsrsquoqualityoflifeas wellasimprovingsocietyrdquo DebraCherryPhD Alzheimerrsquos Association
Theapplicationofthesepublichealthfunctionstocognitive healthoffershopeofsimilarachievementsasscientific knowledgeadvancesTheareaofcognitivehealthisgaining increasingattentionfrommultipleperspectivesandrepresents ablossomingarenaforresearchandactionByembracing cognitivehealthasapriorityissuethepublichealthcommunity wouldbemobilizedtostudyidentifyandimplementeffective interventionsthatpreservethiskeycomponentofhealth Ourchallengeistoofferasystematicapproachthatwill assureacoordinatedandunifiednationaleffortTheRoad Mapmeetsthatchallengebylayingoutasharedvisionfora ldquoworkinprogressrdquoonethatbuildsonthefoundationofthe workdonetodateestablishesaframeworkwithinwhichto viewthefindingsofthatworklinksrelatedandcomplementary activitiesandshapestheworkofthefuture
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
I background
II state of
knowledge
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
Strategic Framework What is our model for action
TodeveloptheRoadMapweusedaldquosynergisticrdquomodel (Figure1)formovingscienceintopublichealthpractice38 Themodelstartswiththeassumptionthatwemustfirst understandtheexisting science and knowledge baseforpreserving andprotectingcognitivehealthdeterminefindingsreadyto
bemovedintothepublichealtharenaandthenconduct researchtofillimportantgapsinknowledge
Atthesametimewemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnew knowledgeThepushofscienceandthepullofthemarket combinetoshapethecapacitymdashthecomplementofhuman andfinancialresourcesmdashwemusthaveinplacetoimprove
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
StrategicFramework
Figure 139 The Model Moving Science into Public Health Practice
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies resources
partnerships etc)
Createexpand the science and knowledge base
Createsustain social environmental demand
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
publichealthpracticeStrengtheningandbuildingcapacity focusesonidentifyingkeypublichealthentitiesdetermining thenecessarycompetenciesandresourcesandexpanding partnershipstomountandsustainnecessaryactions Deployingthiscapacityeffectivelywillleadtodesired intermediate and long-range outcomes
What principles do we embrace
Severalkeyprinciplesunderlieourapproachtomaintaining cognitivehealth
A firm grounding in science Epidemiologicstudies followedbythetestingofinterventionsinclinicaltrialswith componentsthatincludecognitiveassessmentwillshow whichlifestylefactorsbestmaintaincognitivehealthfor thepopulationThroughpopulation-basedsurveillance epidemiologyandpreventionresearchpublichealthcan contributetoourunderstandingofcognitivehealthandcan identifypromisinginterventionsthatmaybeeffectivein promotingorprotectingitTheRoadMaprecognizesthat thisprocessisevolutionaryanditseekstobuilduponwhat wecurrentlyknowbyincorporatingnewdiscoveriesas theyemerge
ldquoThepossibilityofprevention inthisareaissonewand soexcitingforfamilies individualsandgovernmentrdquo JamesLaditkaDAPhDMPA University of South Carolina
An emphasis on primary preventionPublichealth focusesonreducingthefactorsthatputpeopleatriskof cognitivedeclinewhileincreasingthefactorsthatpromote andprotectcognitivehealthThustheRoadMapfocuses oninterventionsinhealthpromotionandriskreductionthat preservecognitiveperformancemdashratherthanpreventdementia Itrecognizesthepotentialldquosynergisticrdquoapproachbyintegrating theseinterventionswithotherlifestylemessagesandshowing howtheymightfitwithpharmacologicinterventions
A community and population approach Publichealth takesabroadviewandseekstoachievelastingchangein thehealthofentirepopulationsextendingfarbeyondthe medicaltreatmentofindividualpeopleThustheRoadMaprsquos recommendationsareexpansiveinscopeanddonotsingle outanyparticularpeopleorgroupsforspecialattention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
StrategicFramework
A commitment to eliminating disparities Racial andethnicdisparitiesinhealthandhealthcarearewell documentedTheeliminationofsuchdisparitiesisacritical componentofthenationalpublichealthagendaandakey principleofthisRoadMapaswell40Thenumbersand proportionofolderadultsfromdiverseracialandethnic originsintheUnitedStatesareincreasingIn2003nonwhite ethnicandracialgroupsrepresented17ofthepopulation age65andolderwiththatproportionprojectedtoincrease to28by2030and39by205041Weembracethis diversityandrecognizeitsvalueinshapingpolicyinitiatives communicationstrategiesandlifestyleinterventionsand population-basedsurveillancerelatedtocognitivehealth
What do we hope to accomplish
Weenvisionanationinwhichthepublicembracescognitive healthasapriorityandinvestsinrelatedhealthpromotion andresearchToachievethisvisionwehaveadoptedalongshytermgoalandavarietyofoutcomesasmoreimmediategoals
Our long-term goal is to maintain or improve the cognitive performance of all adults
Fourteenintermediateoutcomesencompasstheareasof communicationsurveillanceresearchpolicyandpublic healthcapacityTheseareto
bull Increaseawarenessabouttheimportanceofpromotingand protectingcognitionamongthegeneralpublicpublichealth andagingprofessionalsandpolicymakers
bull Increaseknowledgeabouttheriskandprotectivefactors associatedwithcognitionamongthegeneralpublicand publichealthandagingprofessionals
bull Decreasemisconceptionsandmythsaboutcognitivehealth amongthegeneralpublic
bull Determinecriticalpublichealthmeasuresformonitoring cognitivefunctionatthepopulationlevel
bull Incorporateappropriatecognitivemeasuresintopublic healthsurveillancesystems
bull Identifytheresearchgapsonmodifiableriskfactors andcognition
bull Securesustainedsupportforpublichealthresearch topromoteandprotectcognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ldquoIfwemaintaincognitive functionovertimethen wearemorelikelytobe functionallyindependentrdquo MarilynAlbertPhD Johns Hopkins Medical Institutions
bull Disseminatetheresultsofcriticalpublichealthresearch findingsaboutcognitivehealth
bull Identifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Modifykeypublicandprivatepoliciestoaddress cognitivehealth
bull Identifysuccessfulpublichealthbestpracticesonvascular healthanddiabetes
bull Increasecognitivehealthinterventionsthatare complementarytovascularhealthanddiabetespublic healthstrategies
bull Securesustainedsupportforpublichealthstrategiesto promoteandprotectcognitivehealth
bull Enhancethecapacityofagingandpublichealthservice networkstoimplementeffectiveinterventionstopromote andprotectcognitivehealth
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
IV development
process
III strategic
framework
II state of
knowledge
I background
V actions by
cluster
VI next steps
Development Process Phase I Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyand collaborativelyovera7-monthperiodtoidentifyrecommen dationsinfourareasofpublichealthactionPrevention ResearchSurveillancePolicyandCommunicationThe chargetoeachworkgroupwastodefineitsareaoffocus identifyimportantprinciplesandrecommendactionsfor
movingthenationforwardoverthenext3-5yearstoward thelong termgoalofmaintainingandimprovingthe cognitivefunctionofadultsThedefinitionsandprinciples thatemergedarepresentedbelow
Prevention Research Research in public health prevention isdefinedhereasresearch thatappliesandtestspopulation-basedinterventionsthathave
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
DevelopmentProcess
thepotentialtomaintaincognitivehealthRecommendashytionsforcognitivehealthfocusprimarilyontwoareasmdash vascularriskfactorsandphysicalactivitymdashwithemphasis ontheneedforpracticalclinicaltrialstoshowthebenefits ofvascularhealthinterventionsandphysicalactivityon maintenanceoflong-termcognitivehealthTheseareas werechosenbecausetheyarethefirsttoemergefrom population-basedstudiesandanimalresearchaspromising areasforinterventionWhiletheepidemiologicevidence supportingthebenefitsofvascularhealthforcognitive functionismoredefinitivethanthelinkregardingphysical activitybothareasareworthyofattentionInadditionrecent findingsfromclinicaltrialshaveheightenedinterestinthe valueofmentalactivitiesbyshowingapositiveeffectfrom cognitivetrainingoncertaincognitivedomains
Researchonpreventionshouldnotbelimitedtotheseareas howeverOtherareas(suchasnutritionandsocialengagement) shouldalsoberecognizedasimportanttoaddressinthefuture Totheextentpossibleresearchshouldbemultidisciplinary andbuildonafirmunderstandingofhowthepublichealth careprofessionalsandavarietyofotherpartnersdefine perceiveandvaluecognitivehealthInadditionresearch methodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettingshowto makeclinicalorevidence-basedworkpracticalandhow totranslateresearchintopublichealthpractice
Surveillance Surveillanceisdefinedasldquotheongoingsystematiccollection analysisinterpretationanddisseminationofhealth-related datardquo424344Theongoingnatureofpublichealthsurveillance itsapplicationtobroadpopulationsandlimitationsinresources oftenrestrictthenatureanddepthofinformationthatcan begatheredthroughtraditionalsurveillancemethodsused inresearchThesemethodsrangefromcreatingnew surveillancesystemstousingorenhancingexistingsystemsmdash andsurveillanceofcognitivefunctionisnoexceptionSelecting appropriatesurveillancemethodsforcognitivedeclinepresents someuniquechallengeshoweversuchasdefiningcriteriafor acognitivemoduleandmeasuringavarietyofdimensions (egriskfactorsattitudesandburdenofcaregivers)Inaddition becausemeasurementsmayvaryaccordingtoeducation languagecultureandraceorethnicityspecialcaremustbe takentoensurethatdataarenotmisinterpretedormisused
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Methodsavailableforthesurveillanceofcognitivedecline inolderpopulationsthatdonotrelyonself-reportingface particularconstraints
Cognitivedeclineinindividualpeopleisdirectlyidentified throughrepeatedmeasurementsconductedoveraperiod oftimeToimplementthismethodofcaseascertainment inasurveillancesystemrequireslong-termfollow-upof population-basedcohortswithopen(continuousorsuccessive) enrollmentsSuchsystemsarenotoftenusedforchronic diseasesurveillanceastheyareexpensiveandrequirean extensivetimecommitmentfromparticipants
Repeatedcross-sectionalpopulationsurveysaremore commonlyemployedinsurveillanceparticularlyforsome chronicdiseasesandforsomeriskfactorsfordisease Unfortunatelytherearenocurrentlyestablishedmethods thatdefinitivelyascertaincasesofcognitivedeclinethrough cross-sectionalinterviewsaloneSelf-reporteddataare inaccurateinthisareaandtheusefulnessavailabilityand validityofproxy-reporteddataareuncertainDespitethese limitationssuchsurveyshavevalueinmeasuringthe prevalenceofriskfactorsforcognitivedeclineTheymay alsohavepotentialtomeasuresomeparametersofcognitive
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
DevelopmentProcess
functionsItispossiblethatchangesovertimeinthe populationdistributionofsuchparametersmaysuggest changesintheprevalenceofcognitivedeclinealthough suchinferencescanonlybemadewithcautionevenafter controllingforconfounderssuchaseducationcultureand socioeconomicstatus
Othermethodsofscreeningoridentifyingconditions associatedwithcognitivedecline(eggeneticscreening biomarkersandneuroimagingtests)donotyetappear practicalalthoughsomemayeventuallyproveusefulifthe costsarereasonable
Recommendationsforsurveillancemustbeofferedwiththese methodologicalconstraintsinmindrecognizingthetension betweenidealmethodsforwhichresourcesmaybedifficult toobtainandmorelimitedmethodsforwhichresourcesare morelikelyavailable
Policy RealizationoftheRoadMaprsquosvisionrequiresapolicybase inboththepublicandprivatesectorsthatsupportsand promotescognitivehealthThepublic sectorencompasses policymakersatfederalstateandlocallevelsTheprivate sector includesbothnot-for-profitandcommercialorganization
policiessuchascoverageofpreventionbyinsurershuman resourcedepartmentpoliciesemployeeassistanceprograms andotherworkplacepoliciesandpracticesPolicychanges inthepublicsectorcaninfluencepoliciesandbehaviorsinthe privatesectorconverselyprivatesectorpolicychangecan influencepublicpolicy
Toeffectpolicychangethepublichealthcaseforaddressing cognitivehealthmdashthefactthatobservationalevidenceand limitedshort-termclinicaltrialsnowexisttosupportsome preventionopportunitiesinthisareamdashmustbemadeinan easilyunderstandableandconsistentmannerNationalstate andlocalorganizationsagenciesandpolicymakersmustbe educatedaboutcognitivehealthandsubsequentlyengaged tohelppromotepositivepolicydevelopmentandchangethat willincreaseknowledgeandleadtobettercognitivehealth
Moreoverpolicyrelatedtomaintainingcognitivehealthdoes notjustaddresscarebehaviorsorriskfactorsbutalso promotesresourcesforbuildingandmaintainingcommunity infrastructurethatreinforcesindividualbehaviorThiscould includebikeorwalkingtrailstoencouragephysicalactivity community-wideorganizationsandstructuresthatsupport healthybehaviorandotherchangestothebuiltandcultural
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ldquoDevelopingaroadmapforcognitivehealthprovidesus withanopportunitytoreducehealthdisparitiesSome populationsareathighriskforcognitiveimpairmentdue tohighratesofhypertensionordiabetesTheRoadMap givesusachancetoprovidebetterhealthinformationforall Americansincludingthoseathighestrisksothatpeoplemay improvetheirmotivationtochangetheirlifestyleforbetter healthoutcomesrdquo DebraCherryPhD Alzheimerrsquos Association
environmentsthatadvancethepublichealthgoalofcognitive healthPolicyinitiativesmustbuilduponrelatetoandbe compatiblewithcommunicationsandresearcheffortsasthey takeshapeandyieldnewinformation
Communication Thetermcommunication strategyimpliesamultidisciplinary healthmarketingapproachthatincludescommunicatingand disseminatingscientificallyvalidinformationandstrategic interventionsthroughcustomer-centeredandculturally appropriatemeansAcommunicationsstrategyforcognitive healthaimstoeducatemotivateandeffectpositivebehavior changerelatedtocognitivehealthintargetedandat-risk audienceswithin3years
Toeffectivelyreachthisgoalcommunicationmessagesand methodsshould
bull Besciencebased
bull Begearedtopopulationsexperiencingthegreatest disparitiesandrisksincognitivehealth
bull Reachtheintendedaudienceandpromoteaction
bull Assisttheconsumerinmakingmoreinformeddecisions
Theaudienceofadultsaged42-60yearsalsoknownas babyboomersbelongstothebiggestgenerationinAmerican historyCognitivehealthissuesprofoundlyaffecttheirparents nowandtheywilltouchtheboomersinhugenumbersas theygrowolderItisimportanttogetappropriatevalid evidence-basedmessagestothemsotheymaytakeaction forthemselvesaswellaspotentiallyinfluencetheirfamilies Specialfocusshouldbegiventohighriskpopulations vulnerablepopulationsandhealthcareprovidersSpecific racialorethnicgroups(egAfricanAmericansLatinos)may needtohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheymaybeatgreaterriskfor
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
DevelopmentProcess
experiencingcognitivedeclineduetohigherrisksofvascular diseasehypertensionanddiabetesHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthegeneral publicbecausetheyareprovidinginformationaboutcognitive healthtoothersAninitialfocusonthesegroupswouldnarrow thescopeofeffortaffordingmoreachievableoutcomes
Inadditionbeforereachingouttoconsumersaccurate informationandoptionsshouldbeinplacethroughoutthe broadermedicalandsocialserviceenvironmentHealthcare professionalsarethemainsourceofinformationformany consumersandpastexperiencehasproventhebenefitsof targetingprofessionalorganizationsfirstaspeerinfluencers andtrainersofthesefrontlineproviders
Phase 2 mdash Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations 18inpreventionresearch8incommunications9inpolicy and7insurveillanceAconcept-mappingprocesswasthenused toorganizeandvisuallyrepresentthemConcept-mapping combinesqualitativeandquantitativemethodstogenerate mapsthatprovideavisualrepresentationofthecomplex relationshipsamongideasandresults45Itcanelicitideasfrom
largediverseandgeographicallydispersedgroupsabout aparticulartopicwithinashorttimeframeUnlikeother qualitativemethodsconceptmappingalsoprovidesastructured approachthatallowskeydecisionmakerstoparticipateinthe finalinterpretationofalargergrouprsquosperceptions
Forthisprojectconcept-mappingwasorganizedinto threesteps
Step 1involvedreviewingandrestructuringrecommendations fromtheworkgroupstoensurethateachrecommendation representedadistinctideaandidentifyingthelistof stakeholderswhowouldbeinvitedtoparticipateThislist includedmorethan150personsfromabroadarrayof institutionsincludingstateandfederalagenciesuniversities andfoundations
Step 2consistedofonlineratingandsortingbyinvited participantsandsubsequentanalysesoftheresults46Forthe ratingprocess140(ofthe150)participantswereaskedto rateboththerelativeimportanceofeachrecommendation anditscurrentactionpotentialForthesortingtask20of these140participantswerealsoaskedtocategorizethe recommendationsaccordingtotheirviewofsimilarmeanings orthemesTen(ofthe150)participantswereinvitedto
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ldquoIamveryimpressedwiththeprocessbecausethisisafieldin whichpeoplehavestrongopinionsonmanydifferentissues Whatimpressedmewasthattheparticipantsinthereview processwereopentohearingabroadrangeofopinionsbut intheendoptedforscientificrigorastheguidingfeatureon whichrecommendationswerebasedrdquo PeterRabinsMDMPH CoauthorThe 36 Hour Day
participateinthesortingtaskonlyBecausetheratingand sortingprocesswasanonymousexactfiguresonparticipation arenotavailablehoweverbasedonthenumberoftotal responses69persons(outof140or493)providedinput intoratingtheimportanceandactionpotentialofeach recommendationAdditionally23persons(outof30or 767)organizedtherecommendationsintocategoriesto identifythemesorpatternsMultivariatestatisticaltechniques wereusedtoorganizeandvisuallypresentresultsofthe onlineprocessinaseriesofconceptmapsthatreflected relationshipsbetweenrecommendationsandtheclustering ofrecommendationsintocategories
Step 3 encompassedthereviewandinterpretationofthe resultsofPhase2andselectionofpriorityrecommendashytionsMembersoftheSteeringCommitteereviewedthe mapstoensurethattherecommendationsineachoftheeight clusterswereconsistentwiththeoverallthemeofthatcluster
TheCommitteereconstructedafewrecommendations creatingtwoadditionalrecommendations(foratotalof 44recommendations)andintwoinstancesmovedrecomshymendationstoadifferentclusterThefinalclusterlabelsare
bull Disseminatinginformation bull Translatingknowledge bull Conductingsurveillance bull Implementingpolicy bull Measuringcognitiveimpairmentandburden bull Movingresearchintopractice bull Conductinginterventionresearch bull Developingcapacity
AsafinalsteptheSteeringCommitteechoseasetof priorityrecommendationsoractions
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
I background
II state of
knowledge
III strategic
framework
IV development
process
V actions by
cluster
VI next steps
Actions by Cluster TheRoadMapisaldquolivingrdquodocumentexpectedtoevolve overtimeSomeactionsareachievablewithin1to3years whileotherswillrequiremoretimetocometofruition Somearelinkedandneedtooccurinacertainsequence withtheoutcomesofthefirstsettingthestageforinitiating thenextAndwhilenoparticularagegroupissingledoutfor specialattentiontheRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadultsThisfocus recognizesthatinterventionstoreducerisksarebestbegun earlyinlifeyetadultsparticularlyolderadultsaremore likelytobeconcernedandmotivatedtotakeaction
ThefullsetofRoadMapactionsfallintoeightclusters Withineachclustertheactionsarelistedinnospecialorder ofpriorityTheletterinparenthesesaftereachactionrefers
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ActionsbyCluster
tothegroup(eitherworkgrouporSteeringCommittee) thatoriginallyproposedit(P=PreventionResearch C=CommunicationP=PolicyS=SurveillanceSC=Steering Committee)Alloftheactionsgeneratedbythegroups areincluded
Inofferingtheseactionswecannotunderestimatethe complexitiesoftranslatingthemintoactionMostessentialis acommitmenttobasethisRoadMaponscientificevidence movingforwardcollaborativelytoleverageexistingresources andactivitiesaspromotionactivitiesbecomedefinedKey partnershipsmustbeformedamongadiversearrayof organizationsandagenciestobuildoncollectivestrengths delivercompatiblemessagesandinterventionsandassure efficientuseofresourcesExistinghealthpromotion communitiesassociatedwithheartdiseasestrokediabetes andphysicalactivityareinvaluableresourcesforpromoting cognitivehealth
Disseminating information
1 Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions (SC) Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelping thepublictounderstandthevaryinglevelsofevidence behindproposedinterventionsregardingcognitivehealth Unlesscredibleandbroadreachinginformationabout validinterventionsincognitivehealthisdisseminated consumerswillfillthegapwithuntestedprogramsand productsNotonlycantheseprogramsandproducts presentaneconomicburdenbutsomemayalsodistract theagingpopulationfrommeaningfullifestylechanges Communicationsstrategies(includingtheappropriate communicationchannels)shouldbuilduponcurrent effortsbyvariousorganizationsandagenciestoshare existinginformationandmaterialsoncognitivehealth researchandpossibleinterventionsthatareconsistent withcurrentscience
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
2
3
Develop communications strategies and tools
to increase awareness among health care providers
public health professionals and aging service
providers at the national state and local levels about
the current state of science of cognitive health (C) Indisseminatinginformationtothepublicinformation mustbefilteredthroughtrustedhealthandcommunity resourcesProvidingprofessionalswithaccurateevidenceshybasedinformationandtoolswillrespondtothegrowing interestamongconsumersregardingquestionson preservingcognitivehealth
Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals (P) Toincreasetheawarenessandknowledgeofprofessionals inhealthandhumanservicesstrategiesshouldbedeveloped inbothpreserviceandin-servicemodalitiesBringingnew professionalsintothefieldwithappropriateknowledge isnotenoughthelevelofunderstandingofpracticing professionalsmustalsoberaisedsothattheycanhelpthe publicsortoutevidence-basedapproachestocognitive healthfromlessprovenorundemonstratedoutcomes
4
5
Develop creative and replicable means for raising
the publicrsquos awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy (P) Thepublicplaysanimportantroleinstimulatingboth publicsectorandmarketplaceactiononissuesitfinds importantItisessentialthatthepublicbeeducated basedoncurrentscienceandknowledgeofbest practicesThiswillcontributetothedevelopmentof anewconventionalwisdomregardingcognitivehealth
Establish and maintain a Web-based cognitive
health clearinghouse in partnership with
stakeholder organizations that would be
recognized as a centralized site for scientifically
validated and recognized information (C) Aone-stop-shopgo-toplaceforvalidandtested informationwillprovideconsumersandprofessionals whoserveolderadultsandtheirfamilieswiththetools tomakeinformeddecisionsabouttheirhealthandeffect positivebehaviorchangeThesitewouldprovideguiding principlestohelpconsumersandhealthinformation providersandprofessionalstoevaluatelocalservices thataddresstheseconcernsandtomaintaincurrent
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ActionsbyCluster
understandingaboutcognitivehealthandthese interventionsasthesciencebecomesmoresophisticated
Translating knowledge
1 Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors (R) Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelop usefulprogramsitwillbeimperativetobetterunderstand thediversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththe generalpublicandpractitionersincludehowcognition isdefinedandtranslatedwhataspectsofcognitivehealth areimportant(includingthelevelofknowledgeabout vascularfactors)andhowconcernedthegeneralpublic isaboutcognitivehealth
2 Help people understand the connection between risk
and protective factors and cognitive health(CSC) Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinother studiesOfprimaryinterestareaspectsofpersonaland environmentalexperiencesthatmakeitmorelikely(risk factors)orlesslikely(protectivefactors)thatpeoplewill experiencecognitivedeclineConsiderationshouldbe giventotheseconnectionsandtopromotingabetter understandingofitincludinganunderstandingofareas inwhichclinicaltrialshave(orhavenotyet)established acauseandeffectbetweenriskandprotectivefactorsand cognitivehealth
3 Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility (C) Currentlythepublichasnosinglesourceofinformed andvalidrecommendationsforprogramsservicesand lifestylerelatedinterventionstoaddresspositivemeasures incognitivehealthCreatingasystemforreviewingthe growingnumberofprogramsandprovidingpublicaccess tothereviewsgeneratedwillmoveconsumerscloserto informeddecisionsandmorepositiveinvestmentsinhealth
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Implementing policy
1 Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials(P) Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesector alonewillbeinsufficienttoreachdesiredresultsBecause programandfundingdecisionsaremadebypolicymakers atthenationalstateandlocallevelsitisimportantto engageandeducatethisaudiencePublicofficialshave significantcompetinginterestsitisessentialthatthey becomeeducatedandengagedinthisarenatocontribute topositivepolicychangeincognitivehealthinterventions andtosupporttheneedforfurtherresearch
2 Include cognitive health in Healthy People 2020
a set of health objectives for the nation that will
serve as the foundation for state and community
public health plans (P) ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ActionsbyCluster
maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
3 Include the public health burden of cognitive
impairment in the State of Aging and Health
in America Report when population level data
are available (P) Includingcognitivehealthinsuchdocumentsasthe State of Aging and Health in America Reportwouldelevate itsstatusasarecognizedpublichealthissueandmakedata readilyavailableforactionArmedwithimportantdata fromthisandothermonitoringsystemspublichealth professionalswillbepreparedtomovepolicyforwardto testinterventions
4 Promote appropriate strategic partnerships among
associations government agencies insurers and
payers private industry public organizations and
elected officials to support and advance research
and policy related to cognitive health (P) Partnershipscanhelptomaximizelimitedresources (fiscalandpersonnel)andcompetingpriorities
Theyshouldbebaseduponsuchcriteriaastheability toexamineevidence-basedresearchestablishon-going formsofdialoguebuildleadershipandcapacityrelated topolicyandpublicandprofessionaleducationaddress diverseculturalandethnicpopulationsprovidefunding andexplorethelinksbetweenthevascularfactors physicalactivityandcognitivehealth
5 Engage national organizations and agencies that
focus on the older population and educate these
agencies about cognitive health and its connection
to their missions(P) Toachievebroadeffectivecollaborationsforcognitive healthandemotionalwell-beingnationalorganizations andagenciesmustidentifyandagreetocommon groundNationalorganizationsandagenciesareessential tobothreachinglargenumbersofindividualmenand womenandtousingtheirinfluencetoeducatepolicy makersandopinionleadersEducationofthepublicand leadersofkeyorganizationsisaprecursortopolicy changerelatedtocognitivehealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
6 Convene policy experts to identify and examine
current policies (eg national policy state
policy private sector policy) that could be
modified modernized or broadened to include
cognitive health(P) Policiesshouldbeamendedtoreflectcurrentscience andknowledgeandbeinclusiveofcognitivehealth Adjustingandamplifyingcurrentpoliciesareefficient andeconomicalroutestosystemschange
7 Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate(P) Nationalandstatepublichealthplanssignificantly influenceeffortsinpublichealthandserveasa barometerofimprovementAsinterventionsare demonstratedthatcanhaveaneffectoncognitive healthincludingitintheseplanswouldelevateits statusasarecognizedpublichealthissueandprovide avenuefortheevaluationofprogress
Conducting surveillance
1 Define the goals of a surveillance system to
promote the development of an appropriate system
and the collection of data on cognitive health (S) Clearlydefinedgoalsofpublichealthsurveillancewill promotethedevelopmentofappropriatesurveillance systemsandthecollectionofconsistentdatathatprovide usefulinformationtoinformpublichealthpolicyGoals ofthesurveillancesystemmayincludedefiningtheburden ofcognitivedeclineinthepopulationmonitoringthe trendsinburden(egprevalenceincidence)monitoring trendsinriskfactorsdefiningthepopulationatincreased riskanddeterminingwhetheradditionalanalysesshould beperformedforthepurposeofpublichealthsurveillance
2 Determine which existing general population-based
surveillance systems include information useful for
the surveillance of cognitive health at national state
and local levels (S) Addingtoorchangingexistingsurveillancesystems(eg BehavioralRiskFactorSurveillanceSystemHealthand RetirementStudyNationalHealthInterviewSurvey)to
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ActionsbyCluster
addressissuesrelatedtocognitivedeclineislesscostlyand maybemoreefficientthandevelopingnewsurveillance systemsHoweverthereareimportantlimitationsofexisting systemsandthedatatheycollectinparticularmostarecross sectionalratherthanlongitudinalManyarealreadyquite lengthywithmajorconstraintsonaddingnewitems Closeexaminationofthesesystemswillensurethatthey areamendedappropriatelyandcost-effectively
3 Identify existing studies that measure longitudinal
trends in cognitive function(S) Existinglargecohortorotherlongitudinalstudiesof cognitivedeclinemayprovideitemsthatcouldbe incorporatedintosurveillancesystemsformeasuringsuch declineSomeofthesestudiesmayhavevalidateditems usedpreviouslyinbothmajorityandminoritypopulations thatestimatevariabilityandtruechangeovertime
4 Develop a population-based surveillance system
with longitudinal follow-up that is dedicated to
measuring the public health burden of cognitive
impairment in the United States (S) Apopulation-basedsurveillancesystemwouldassistin thecollectionofconsistentdatatomonitorassessand
informpublichealthprogramsandpolicyaboutthe publichealthburdenofcognitiveimpairment
Moving research into practice
1 Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity)
and related interventions for relationships with
cognitive health harms gaps and effectiveness (R) Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
2 Conduct systematic literature reviews on proposed
risk factors (social engagement nutrition
and mental activity) and related interventions
relationships with cognitive health harms gaps
and effectiveness(RSC)
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbe documentedandremaininggapsinthefieldshould beidentifiedinordertomovestrategiesintopublic healthpractice
3 Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health (R) Someevidencesuggeststhatdiabetesisariskfactorfor cognitivedeclineRecommendationsfortypesofdiabetes management(egmedicationslifestylemodification)that mightalsobebeneficialforcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatingdiabetes interventionstocognitivechange(andmostlikely undertakingadditionalclinicaltrials)andidentificationof areasthatneedtobeclarifiedbeforespecificinterventions canbeproposed
4 Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health(R) Hypertensionisaknownriskfactorforstrokeand thereforeforvasculardementiaandcognitivedecline Recommendationsfortypesofantihypertensivetherapy andtherangesofbloodpressurefordifferentagegroups recommendedformaintainingcognitivehealthcannotbe madewithoutareviewoftheliteraturerelatinghypertensive interventionstocognitivechangeandprobablynot withoutpursuingadditionalclinicaltrialsThesystematic literaturereviewwouldidentifyareasthatneedtobe clarifiedbeforespecificinterventionscanberecommended
5 Identify gaps in knowledge about cognitive health
and related lifestyle changes and determine
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ActionsbyCluster
whether these vary by specific groups (C) Todevelopappropriatematerialsandtoolsthegapsin
knowledgeneedtobeunderstoodespeciallyamong high-riskpopulationsvulnerablepopulationsandhealth careproviders Specificracialorethnicgroupsmayneed tohavetargetedandculturallyappropriatematerialsand toolsdevelopedbecausetheyareatgreaterriskfor experiencingcognitivedeclineHealthcareprovidersmay haveneedsandgapsinknowledgethatdifferfromthe generalpublicbecausetheyarealsoprovidinginformation toothersaboutcognitivehealth
6 Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance (R) Understandingthebenefitsofandbarrierstoadopting andmaintaininganinterventionisoneofthecriticalsteps fortranslatinginterventionseffectivelyandefficaciouslyin acommunity-basedsetting
7 Conduct reviews of the literature to determine
the prescriptions for physical activity (eg type
frequency duration and intensity of activity) that
are effective in enhancing cognitive function(R) Itisimportanttoknowwhatkindsofphysicalactivity stimuliarenecessarytopromotecognitivehealthAn examinationofthescientificliteraturewillidentifygaps inknowledgeandfocusresearchWithoutsuchinformation andresearchdevelopmentaccurateadvicecannotbe conveyedtothepubliconhowactivetheyshouldbeto maintaintheircognitivehealth
8 Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions (CSC) Clinicaltrialsassessingtheefficacyofinterventionsto effectcognitivefunctionandpublichealthstudies examiningtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparatelyMore comprehensiveapproachesinvolvingcollaborations betweenclinicalresearchersandcommunityparticipatory researchersarecriticaltoensurethattheeffectivenessand feasibilityofcognitivehealthinterventionsaredeveloped andtestedwithvariouscommunities
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Conducting intervention research
1 Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function (R) Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
2 Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cogshy
nitive decline and improving cognitive function (R) Todatefewifanyphysicalactivitystudies(including large-scalecontrolledclinicaltrialsofolderadultcohorts) havecombinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
3 Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function (R) Todatestudiesofphysicalactivityinterventionsthathave assessedcognitiveoutcomestypicallyhavenofollow-upat alloronlyashortfollow-upStudiesofphysicalactivity
areneededtodeterminetowhatextentanycognitive benefitsassociatedwithphysicalactivitypersistacrosslongshytermfollow-upat6month1yearorlongertimeperiods Long-termfollow-upstudiesofphysicalactivityarealso neededtodeterminethedurationofcognitiveeffectsin thosewhostoptheprogram
4 Conduct studies to determine the physical activity
prescription (eg type of activity frequency
duration and intensity) needed to maintain or
promote cognitive functioning (R) Smallclinicaltrialshaveshownthataerobicactivity (egwalkingseveraltimesaweekfor6monthsduration) wascapableofproducingcognitiveimprovementin olderadultsatleastintheshorttermThesefewstudies howeverhaveyettoyieldaldquoprescriptionrdquothatcould begiventoolderadultsthusmanyquestionsremain tobeansweredaboutthetypesofactivity(egaerobic oranaerobicindividualorgroup)andtheirduration intensityandfrequencythatareneededtomaintainor evengaingoodcognitivefunction
5 Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ActionsbyCluster
different backgrounds in relation to cognition (R) Similartothepharmacogeneticsapproachthathasbeen usedtodeterminetheefficacyofspecificdrugsforpersons withcertaingenotypesitseemspossiblethatrecomshymendationsforbehavioralinterventionssuchasphysical activitymightbecraftedtoanindividualpersonrsquos background(eggeneticendowmentculturalcontext lifehistoriesfitnesslevelsandage)
6 Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living(R) Itisimportanttounderstandhowanycognitivebenefit measuredinthelaboratorytranslatestobetterfunctioning inrealworldtasksAlthoughwell-controlledlaboratory studiesareessentialtoadvancingknowledgeinthisarea itiscurrentlynotclearhowmuchthecognitivetasks assessedinthesestudieswillgeneralizetothecognitive functioningrequiredinroutinedailyactivitiesimportantto olderadultssuchasbalancingacheckbooksafelydriving acarandcompliancewithprescriptionsformedications (ieknowinghowmanyorwhatpillstotakewhen)
7 Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition (R) Itisrecognizedthatsecondaryanalysesofexistingdata setsoftenpossessmethodologicalproblems(including crosssectionaldata)Neverthelessdatasets(perhapseven somerepresentativeoftheUSpopulation)mayexistthat containvariablesrelatedtocognitivefunctioninghealth andphysicalactivityEffortstolocatesuchdataandto evaluateresearchquestionsandassociationsamongthe variablesmayprovideadditionalinsightsintothisarea
8 Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning(R) Physicalactivitymaynotaffectcognitivefunctiondirectly butitmaystillaffectitthroughintermediatemechanisms Itisimportanttoknowwhethertheassociationbetween physicalactivityandcognitivefunctioningismediated bychangesindiabetesoutcomesinvascularfitness outcomesorinriskfactorssuchashypertension orhyperlipidemia
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
9 Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies(R) Thebestwaytounderstandwhichinterventionsin cardiovasculardisease anddiabeteswillaffectcognitive healthisforappropriateaspectsofcognitivemeasurestobe routinelyincludedinappropriatestudiesinthesetwoareas
10 Encourage research to determine the impact of
multiple vascular risks on cognition (R) Specificfocusisneededtobothunderstandthebiology ofhowvascularriskfactorsaffectcognitionandto determinewhethertheeffectsofhavingmultiplefactors areadditiveormultiplicative Someobservationalstudies havesuggestedthatthegreaterthenumberofvascular riskfactorsthegreaterthecognitivedeficitWeknow howeverthatclinicaltrialswithpharmacologicalagents thatcontrolindividualriskfactorshaveeffectivelyreduced vascularriskbuthavenotconsistentlyproducedcognitive benefitAbetterunderstandingofthemechanismsby whichmultiplevascularriskfactorsmaycontributeto cognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficitThebiologicalmechanisms oftheinteractionamongriskfactorsaswellasmodelsof thesizeoftheinteractioneffectoncognitionwouldassist indesigningtrialsofpotentiallyeffectiveinterventions
11 Conduct research on other areas potentially
affecting cognitive health such as nutrition mental
activity and social engagement (R) Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
ActionsbyCluster
Measuring cognitive impairment and burden Usefulmeasurablecomponentsareexpectedtodiffer
1 Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems (S) Itisimportanttorecognizepointsonthecontinuum ofcognitivedeclinethatarefunctionallymeaningful Itshouldalsoberecognizedthatmeasurementsbeyond somepointsonthiscontinuummayrequireinformation fromproxyrespondentsUsefulcomparisonsoffindings fromdifferentsurveillancesystemsandresearchstudiesare improvedifthereisconsistencyamongthethresholds beingusedFunctionallyimportantthresholdsshouldbe ofpracticalsignificancetohelpinformpublichealth policyregardingneedsforcaregiversupportandother specialhealthcareorsocialservices
2 Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems (S) Itisimportanttoknowthekeycomponentsofcognition (egmemoryintelligenceproblemsolvingandreasoning) thataremostsensitiveandspecifictocognitivedecline andpracticallymeasurableinsurveillancesystems
accordingtothenatureofthesurveillancesystem particularlywhetherdatacollectionislongitudinal orcross-sectionalWithcrosssectionaldataalone fewerinferencesarepossibleregardingage-related cognitivedecline
3 Identify measures of the public health burden
of cognitive impairment on individual people
families and communities(SC) Thepublichealthburdenofcognitiveimpairment encompassesitseffectsonindividualmenandwomen caregiversfamiliesemployersandothersinthe communityTheseeffectsmayhavephysicalmental socialandeconomicdimensionsItisimportantto identifykeymeasurablecomponentsoftheseeffectsto enablethepublichealthburdentobefullyassessed monitoredanddescribed
4 Identify a set of questions appropriate for use in
people of diverse educational attainment culture
and ethnicity that will measure cognitive function
with sufficient sensitivity specificity and
predictive values(S)
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Thesequestionsmightexistwithinanongoing population-basedsurveillancesystemortheycould beaddedtosuchasystemTotheextentpossible education-andculture-independentmeasuresshould besoughtBecausetheeffectsofeducationandculture arepotentialconfoundersmeasuresandanalytic techniquesareneededthatwouldenablereduced cognitivefunctiontobedistinguishedfromlow performanceduetovariationsineducationalorcultural exposuresItiscriticaltorecognizeandcorrectthese confoundingeffectssoastoavoidmisinterpretingor misusingsurveillancedata
Developing capacity
1 Engage the private sector and other entities in
planning and funding research to address ways to
maintain and improve cognitive health including
clinical trials (R) Supportofresearchoncognitivehealthisexpensivein scopeeffortandcostPartnershipswithfederalagencies foundationsandotherentitieswilllikelybenecessaryto securesuchsupportandconductthisresearch
2 Convene researchers and community interventionshy
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health(R) Thefieldsofcardiovasculardiseasedepressiondiabetes andcognitionarebeginningtointersectAfterconducting literaturereviewsonwhatiscurrentlyknownaboutthe effectsofinterventionstargetingvascular factorsdepression anddiabetesoncognitivehealthresearchersand communityinterventionistsineachofthesefieldsshould beconvenedtodeterminestrategiesformovingthefield ofcognitivehealthforward
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
IV development
process
V actions by
cluster
VI next steps
III strategic
framework
II state of
knowledge
I background
NextSteps Priorities for action
Whilewebelievethatalloftheactionspresentedinthis RoadMapareimportantwearemindfulofthelimitedpool ofresourceswithwhichtoimplementthemBecauseof thisrealityweselected10actionsofhighestpriorityfor immediateattention
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
NextSteps
bull Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors
Itisnotclearhowthegeneralpublicorpractitioners perceiveandunderstandcognitivehealthTodevelopuseful programsitwillbeimperativetobetterunderstandthe diversetargetaudiencesSomeissuesthatwouldbe importanttounderstandfortranslationtoboththegeneral publicandpractitionersincludehowcognitionisdefined andtranslatedwhataspectsofcognitivehealthareimportant (includingthelevelofknowledgeaboutvascularfactors)and howconcernedthegeneralpublicisaboutcognitivehealth
bull Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions
Evidenceexiststhatthecurrentboomergenerationis concernedaboutcognitivehealthandfearsAlzheimerrsquos diseaseOnecriticalareaoffocusshouldbeonhelpingthe publictounderstandthevaryinglevelsofevidencebehind proposedinterventionsregardingcognitivehealthUnless credibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminatedconsumers willfillthegapwithuntestedprogramsandproductsNot onlycantheseprogramsandproductspresentaneconomic burdenbutsomemayalsodistracttheagingpopulation frommeaningfullifestylechangesCommunications strategies(includingtheappropriatecommunication channels)shouldbuilduponcurrenteffortsbyvarious organizationsandagenciestoshareexistinginformation andmaterialsoncognitivehealthresearchandpossible interventionsthatareconsistentwithcurrentscience
bull Help people understand the connection between
risk and protective factors and cognitive health
Riskandprotectivefactorsarekeystofiguringouthow toaddressindividualandcommunityhealthandrequire clarifyingforthepublicwhatisdemonstratedaseffective inclinicaltrialsversusassociationsobservedinotherstudies Ofprimaryinterestareaspectsofpersonalandenvironmental experiencesthatmakeitmorelikely(riskfactors)orless likely(protectivefactors)thatpeoplewillexperience cognitivedeclineConsiderationshouldbegiventothese connectionsandtopromotingabetterunderstandingofit includinganunderstandingofareasinwhichclinicaltrials
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
have(orhavenotyet)establishedacauseandeffectbetween riskandprotectivefactorsandcognitivehealth
bull Conduct systematic literature reviews on proposed
risk factors (vascular risk and physical inactivity) and
related interventions for relationships with cognitive
health harms gaps and effectiveness
Itiscriticaltoexamineallstudiestodatetodocument whichinterventionshavebeenproveneffectiveSuch reviewsshouldfocusondeterminingtherelationships betweenriskfactorsprotectivefactorsandcognitive functionacrossobservationalandclinicaltrialsWhere interventionsexisttheireffectivenessshouldbedocumented andremaininggapsinthefieldshouldbeidentifiedin ordertomovestrategiesintopublichealthpractice
bull Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function
Todatefewvascularstudies(includinglarge-scalecontrolled clinicaltrialsofolderadultcohorts)havecombinedcognitive healthoutcomesandvascularoutcomesinasinglestudy
bull Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function
Todatefewifanyphysicalactivitystudies(includinglargeshyscalecontrolledclinicaltrialsofolderadultcohorts)have combinedoutcomesforcognitivehealthandphysical activityoutcomesinasinglestudy
bull Conduct research on other areas potentially affecting
cognitive health such as nutrition mental activity
and social engagement
Scienceisevolvingregardingriskandprotectivefactors intheareasofcognitivetrainingnutritionandsocial engagementItiscriticaltomonitorandincludethese areasasthescienceemerges
bull Develop a population-based surveillance system with
longitudinal follow-up that is dedicated to measuring
the public health burden of cognitive impairment in
the United States
Apopulation-basedsurveillancesystemwouldassistinthe collectionofconsistentdatatomonitorassessandinform
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
NextSteps
publichealthprogramsandpolicyaboutthepublichealth burdenofcognitiveimpairment
bull Initiate policy changes at the federal state and local
levels to promote cognitive health by engaging
public officials
Far-reachingpublichealthissuesdemandinformedaction bypublicofficialsbecauseactionbytheprivatesectoralone willbeinsufficienttoreachdesiredresultsBecauseprogram andfundingdecisionsaremadebypolicymakersatthe nationalstateandlocallevelsitisimportanttoengage andeducatethisaudiencePublicofficialshavesignificant competinginterestsitisessentialthattheybecomeeducated andengagedinthisarenatocontributetopositivepolicy changeincognitivehealthinterventionsandtosupport theneedforfurtherresearch
bull Include cognitive health in Healthy People 2020 a set
of health objectives for the nation that will serve
as the foundation for state and community public
health plans
ThedevelopmentanduseofdocumentssuchasHealthy People 2020willrepresentasystematicandwidely recognizedapproachtoimprovinghealthAsresearch demonstrateswaysinwhichcognitivehealthcanbe maintainedtheareaofcognitivehealthcanbeelevated toamajorhealthprioritybybeingincorporatedintothe outcome-orientedapproachusedbyHealthy People 2020
Theseprioritiescutacrosstheclustersandasapackage wouldputourldquobestfootforwardrdquoinmeetingthepublic healthchallengesofcognitivehealthThepriorityactionsput forthrepresentthebestthinkingofleadingexpertsacross diversefieldsofinfluenceTheyhavebeenidentifiedasones thatarenecessarytomovingtheissueofcognitivehealth intopublichealthpracticeWeurgethenationtoadoptthese 10actionsandtojoinforcesinimplementingthemover thenext3-5yearsDoingsowouldbemakingtremendous stridestowardsachievingourlong-termvisionmaintaining orimprovingthecognitiveperformanceofalladults
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Implementation
Effectiveimplementationoftheactionsoutlinedinthis RoadMaphingesonseveralfactors
bull Organizationswillneedtoidentifyclearlywhichactions theywishtoaddressandcollaboratewithothergroupsthat shareaninterestinthoseactions
bull Organizationsshoulddevelopandstrengthenpartnerships withotherlike-mindedorganizations
bull Organizationsshoulddeveloptheirownplanstoachieve theirselectedactions
bull Organizationsshouldestablishsystemstotracktheir progresstowardscompletingtheirplansofactionandto facilitatecommunicationandexchangeofinformation
Asthescienceofcognitivehealthiscontinuallyevolvingthe RoadMapshouldbeviewedasalivingdocumentthatcontains awiderangeofactionsonhowtoproceedAsweachievesome oftheactionswecanusetheRoadMaptomoveforwardand addressotheractionsthatbecomerelevantandfeasible
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterest incognitivehealthisbeginningtomeettheburgeoningdemand ofthepublicforwaystomaintaincognitivefunctionItsetsin motionacourseofactionforestablishingpartnershipsmaking cognitivehealthaprominentpublichealthissueandpreparing societyforconcertedeffortstomaintainingthecognitive healthofolderAmericans
TheRoadMapisbothacalltoactionandaguideforimpleshymentinganeffectivecoordinatedapproachtomovingcognitive healthintopublichealthpracticeThekeytosuccessliesin continuingandexpandingresearchdevelopingandchanneling resourcesandworkingcollaborativelytomovetheevidence aboutmaintainingcognitivehealthintonationalaction
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
AppendixAContributors
Communications Workgroup MaryGuerriero AustromPhD Indiana Alzheimerrsquos Research Center Indiana University School of Medicine
FrankBaileyJD AARP
DianeBazelides Alzheimerrsquos Association National Board
VickyCahan National Institutes of Health
NancyCeridwyn American Society on Aging
MarthaDiSario Pacific Communications Enterprises
BarbaraEGillMBA The Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKenna Centers for Disease Control and Prevention
MichaelCPatterson AARP
DeloresPlutoPhD University of South Carolina
MarySchwartzMS Alzheimerrsquos Association
BobRosenblatt National Academy of Social Insurance
Policy Workgroup WilliamFBenson Health Benefits ABCrsquos
JoyCameron National Governors Association
IrisFreeman Advocacy Strategy
KathrynGallagher Centers for Disease Control and Prevention
RobynGoldenLCSW Rush University Medical Center
CatherineGordonRNMBA Centers for Disease Control and Prevention
MaryGuthrie Administration on Aging
DavidHoffmanMEd New York State Department of Health
JimHoward California Department of Health Services
DebraLappinJD BampD Consulting LLC
StephenMcConnellPhD Alzheimerrsquos Association
SandyMarkwood National Association for Area Agencies on Aging
MarkSchoeberl American Heart Association
PaulTibbitsJr American Diabetes Association
Prevention Research Workgroup MarilynAlbertPhD Johns Hopkins Medical Institutions
MargaretGatzPhD University of Southern California
JNeilHendersonPhD University of Oklahoma Health Sciences Center
KathrynJedrziewskiPhD Institute on Aging University of Pennsylvania
RhondaMontgomeryPhD University of Wisconsin - Milwaukee
MarcelleMorrison-BogoradPhD National Institute on Aging
PeterRabinsMDMPH Johns Hopkins University School of Medicine
MarySanoPhD Alzheimerrsquos Disease Research Center Mount Sinai School of Medicine
JesusSoaresMScScD Emory University Centers for Disease Control and Prevention
WilliamThiesPhD Alzheimerrsquos Association
BarbaraVickreyMDMPH University of California at Los Angeles
MollyWagsterPhD National Institute on Aging
NancyWhitelawPhD National Council On Aging
ShereeMarshallWilliamsPhDMSc Centers for Disease Control and Prevention
KristineYaffeMD University of California San Francisco San Francisco Veteranrsquos Administration Medical Center
Surveillance Workgroup DallasAndersonPhD National Institute of Aging
HughCHendrieMBChBDSc Indiana University Center for Aging Research Regenstrief Institute Inc
WalterldquoBudrdquoKukullPhD University of Washington
JamesNLaditkaDAPhDMPA University of South Carolina
KennethMLangaMDPhD University of Michigan
EricBLarsonMDMPH Group Health Center for Health Studies
LenoreLaunerPhD National Institute on Aging
LisaCMcGuirePhD Centers for Disease Control and Prevention
DanMungasPhD University of California Davis
NathaliedeRekeneireMDMS Centers for Disease Control and Prevention
PaulScherrPhDDSc Centers for Disease Control and Prevention
DavidThurmanMD Centers for Disease Control and Prevention
Centers for Disease Control and Prevention and the Alzheimerrsquos Association |
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
AppendixAContributors
Additional Contributors Averyspecialthankyoutoallofthemen andwomenwhoprovidedfeedbackon therecommendations
RobertBlancatoMPA Matz Blancato amp Associates Inc
AmyRBorensteinPhD University of South Florida
JohnCSBreitnerMDMPH University of Washington
CarolBryantPhD University of South Florida
CarlCaspersenPhD Centers for Disease Control and Prevention
WojtekChodzko-ZajkoPhD University of Illinois at Urbana-Champaign
JamesCooperMD George Washington University School of Medicine
CarlCotmanPhD Institute for Brain Aging and Dementia University of California at Irvine
RodDishmanPhD University of Georgia
CharlesFEmeryPhD Ohio State University
PaulEstabrooksPhD Kaiser Permanente-Colorado
JenniferLEtnierPhD University of North Carolina at Greensboro
DenisAEvansMD Rush Institute for Healthy Aging Rush University
JeffFinn American Society on Aging
PatrickFoxPhD Institute for Health amp Aging University of California at San Francisco
MaryGanguliMDMPH University of Pittsburgh School of Medicine
FrancineGrodsteinScD Harvard Medical School
BradleyDHatfieldPhD University of Maryland
MichaelJohnson OBC Group LLC
ArthurKramerPhD Beckman Institute University of Illinois at Urbana-Champaign
DarwinLabartheMDMPHPhD Centers for Disease Control and Prevention
MichaelWLinkPhD Centers for Disease Control and Prevention
NancyBEmersonLombardoPhD Boston University School of Medicine
EdwardMcAuleyPhD University of Illinois at Urbana-Champaign
GuyMcKhannMD The Zanvyl Krieger MindBrain Institute Johns Hopkins University
ToniPMilesMDPhD University of Louisville
MarkMossPhD Boston University School of Medicine
MarciaOryPhDMPH The Texas AampM University System Health Science Center
RonaldCPetersenPhDMD Mayo Clinic College of Medicine
ScottLParkin National Council on Aging
TomProhaskaPhD The Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamsey Centers for Disease Control and Prevention
GeorgeWRebokPhD Johns Hopkins University
WalterARoccaMDMPH Mayo Clinic College of Medicine
KenRockwoodMDFRCPC Dalhousie University
GailShearer Consumers Union
PhillipDTomporowskiPhD University of Georgia
TerrieFoxWetlePhD Brown University
PeterZandiPhDMPHMHS Johns Hopkins University
Staff LindsayAbrahamMPH Northrop Grumman Centers for Disease Control and Prevention
MarkConner Northrop Grumman Centers for Disease Control and Prevention
KristineLDayMPH Centers for Disease Control and Prevention
SheilaJackMUPMSJ Alzheimerrsquos Association
BrendaPepe Concept Systems Inc
PeterReedPhDMPH Alzheimerrsquos Association
WalkerTisdaleMPH Alzheimerrsquos Association
SusanToalMPH Public Health WriterEditor
CatherineVanBrunschot Concept Systems Inc
0|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
AppendixBReferences
1 EisendrathSJFederAThemindandsomaticillnesspsychologicalfactors affectingphysicalillnessInGoldmanHHeditorReview of general psychiatry4th edNorwalk(CT)AppletonandLange199513ndash9
2 NationalResearchCouncilThe aging mind opportunities in cognitive research Washington(DC)NationalAcademyPress2000
3 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement 2006212-32
4 HimesCOettingerENKennyDEAging in stride plan ahead stay connected keep movingWashington(DC)CaresourceHealthcareCommunicationsInc2004
5 HeronMPSmithBLDeathsleadingcausesfor2003Nationalvitalstatistics reportsvol55no10Hyattsville(MD)NationalCenterforHealthStatistics 2007
6 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
7 AdministrationonAgingA profile of older Americans 2005Washington(DC) DepartmentofHealthandHumanServicesAvailableathttpwwwaoagov PROFStatisticsprofile20053asp
8 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
9 CutlerNEWhitelawNWBeattieBLAmerican perceptions of aging in the 21st
centuryWashington(DC)NationalCouncilontheAging2002 10 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA)
ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
11 KhachaturianZSKhachaturianAS Publichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement 2005120-4
12 HeronMPSmithBLDeathsleadingcausesfor2003 Nat Vital Stat Rep 2007551-92
13 HebertLEScherrPABieniasJLBennettDAEvansDAAlzheimerdiseasein theUSpopulationprevalenceestimatesusingthe2000CensusArchives of NeurologyAugust2003601119-22
14 GrahamJERockwoodKBeattieBLetalPrevalenceandseverityofcognitive impairmentwithandwithoutdementiainanelderlypopulationLancet 19973491793-6
15 LopezOLKullerLHFitzpatrickAIvesDBeckerJTBeauchampN EvaluationofdementiainthecardiovascularhealthcognitionstudyNeuroepideshymiology 2003221-12
16 UnverzagtFWGaoSBaiyewuOetalPrevalenceofcognitiveimpairment datafromtheIndianapolisStudyofHealthandAgingNeurology2001571655-62
17 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
18 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseJAm Geriatr Soc200452187-94
19 KhachaturianZSKhachaturianASPublichealthpremisefornationalresearch prioritiesmortalityversusdisabilityAlzheimers Dement2005120-4
20 NationalAllianceforCaregivingandAARPCaregiving in the US April2004 Availableathttpwwwcaregivingorgdata04finalreportpdf
21 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl JMed 20033491891-2
22 Schulz RMendelsohnABHaleyWEMahoneyDAllenRSZhangS ThompsonLBelleSHResourcesforenhancingAlzheimerrsquoscaregiverhealth investigatorsEnd-of-lifecareandtheeffectsofbereavementonfamilycaregivers ofpersonswithdementiaN Engl J Med 20033491936-43
23 AlzheimerrsquosAssociation25yearsofsupportingscienceandshapingthe AlzheimerResearchAgendaAlzheimers Dement20051
24 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
25 ASA-MetLifeFoundationAttitudes and awareness of brain health pollSan FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
26 ASA-MetLifeFoundationAttitudes and awareness of brain health poll San FranciscoAmericanSocietyonAging2006Availableathttpwwwasaging orgasav2mindalertbrainhealthpollcfm
27 ResearchAmericaAmerican speaks poll data summaryVolume 7 Alexandria(VA) ResearchAmerica2006Availableathttpwwwresearchamericaorg publicationsAmericaSpeaksAmericaSpeaksV7pdf
28 Prigerson HG Coststosocietyoffamilycaregivingforpatientswithend-stage AlzheimerrsquosdiseaseN Engl J Med20033491891-2
29 TheLewinGroupandAlzheimerrsquosAssociationSaving lives saving money dividends for Americans investing in Alzheimerrsquos researchWashington(DC) AlzheimerrsquosAssociation2003
30 BynumJPWRabinsPVWellerWENiefeldMAndersonGFWuATheimpact ofdementiaandchronicillnessonMedicareexpendituresandhospitaluseAm Geriatr Soc 200452187-94
Centers for Disease Control and Prevention and the Alzheimerrsquos Association|
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
AppendixBReferences
31 KoppelRtheAlzheimerrsquosAssociationAlzheimerrsquos disease the costs to US business in 2002Washington(DC)AlzheimerrsquosAssociation2002
32 HendrieHCAlbertMSButtersMAetalTheNIHCognitiveandEmotional HealthProjectReportoftheCriticalEvaluationStudyCommitteeAlzheimers Dement2006212-32
33 AlbertMSBrownDRBuchnerDetalThehealthybrainandouraging populationtranslatingsciencetopublichealthpracticeAlzheimers Dement 20073(suppl1)S3-S5
34 WilsonRSScherrPAHogansonGBieniasJLEvansDABennettDA EarlylifesocioeconomicstatusandlateliferiskofAlzheimerlsquosdisease Neuroepidemiology2005258-14
35 WinslowCEPublichealthatthecrossroads1926Am J of Public Health 1999891645-8
36 InstituteofMedicineDivisionofHealthCareServicesCommitteeforthe StudyoftheFutureofPublicHealthThe future of public healthWashington(DC) NationalAcademyPress1998
37 CentersforDiseaseControlandPreventionTengreatpublichealth achievementsndashUnitedStates1900-1999MMWR Weekly199948(12)241-243
38 AndersonNStartgettingpackedwearemovingtothenextfrontierOutlook 1999(Spring)9
39 OrleansCTHelpingpregnantsmokersquitmeetingthechallengeinthenext decadeTobacco Control 20009(supple3)III6-III11
40 USDepartmentofHealthandHumanServicesHealthy People 2010 understanding and improving health2ndedWashingtonDCUSGovernment PrintingOfficeNovember2000Availableatwwwhealthypeoplegov
41 USCensusBureau2004bUS interim projections by age sex race and hispanic originAvailableathttpwwwcensusgovipcwwwusinterimproj
42 ThackerSBHistoricaldevelopmentInTeutschSMChurchillREeditors Principles and practice of public health surveillance 2ndedNewYorkOxford UniversityPress2000
43 BuehlerJWSurveillanceInRothmanKJGreenlandSeditorsModern epidemiology2ndedPhiladelphiaLippencott-Raven1998
44 TeutschSMThackerSBPlanningapublichealthsurveillancesystem Epidemiological Bull1995161-6
45 KaneMTrochimWMKConcept mapping for planning and evaluationThousand Oaks(CA)SagePublicationsLtd2007
46 OnlineinputwasconductedbyCSGlobalcopy andanalysisofresultsbyThe ConceptSystemCoreversion40copy
|TheHealthyBrainInitiative ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention as the sentinel for the health of people in the United States and throughout the world strives to protect peoplersquos health and safety provide reliable health information and improve health through strong partnerships CDCrsquos mission is to promote health and quality of life by preventing and controlling disease injury and disability
Alzheimerrsquos Association
The Alzheimerrsquos Association is the leading voluntary health organization in Alzheimer care support and research Our mission is to eliminate Alzheimerrsquos disease through the advancement of research to provide and enhance care and support for all affected and to reduce the risk of dementia through the promotion of brain health Our vision is a world without Alzheimerrsquos