USE IT OR LOSE IT: Preventing

Cognitive Decline in Aging

Michael Pramuka, Ph.D.Western Psychiatric Institute and Clinic

University of Pittsburgh Center for Healthy Aging

Other Potential Means of preventing cognitive decline: Management of Depression Diet Food Supplements (anti-oxidants) Exercise Adequate Sleep Stress Reduction Cholinesterase Inhibitors Reduce health risks for vascular

dementia

Past Models of Cognitive Intervention Functional Approach:

– Choose best environment– Develop compensations– Focus on everyday tasks

Cognitive Approach– Rehearse attention, memory,

planning skills– Apply to real-life situations

Past Models of Cognitive Intervention Both approaches resulted in

– Increased awareness of cognitive abilities and limitations

– Poor generalization– Recruitment of intact functions/

preserved brain function Recent increasing evidence of

functional treatment efficacy

Popular Model of Preserving Cognition in Aging

Increased Cognitive Activity– Improved Everyday Function– Slowed cognitive decline

VIA changes in cerebral organization or function

Popular Books Mind Games: The Aging Brain and How

to Keep It HealthyWetzel, Kathryn, & Harmeyer, Kathleen

 The Memory BibleSmall, GaryKeep Your Brain Young

McKhann, Guy & Albert, Marilyn Brain Fitness

Goldman, Robert, Klatz, Ronald, & Berger, Lisa

More Popular Books: Use It or Lose It: How to Keep Your Brain

Fit as It AgesBragdon, Allen. D., & Gamon, David

Keep Your Brain Alive: 83 Neurobic Exercises to Help Prevent Memory Loss and Increase Mental Fitness

Katz, Lawrence C., & Rubin, Manning Reversing Memory Loss: Proven Methods

for Regaining, Strengthening, and Preserving Your Memory

Mark, Vernon H., & Mark, Jeffrey P.

 More Popular Books Exercises for the Whole Brain

Bradgon, Allen D.  Exercise Your Mind

Castorri, B. Alexis

All popular books have one thing in common: they cite one or several studies that implicate cognitive activity as a means of staving off Alzheimers or improving performance, and then go on to cite many activities, compensations, or strategies for improving cognition

Professional Literature: More Active Lifestyles Predict Preserved Cognitive Function Comes from both cross-

sectional and longitudinal data

Few studies provide a comprehensive or parallel literature review

Professional Literature: Measuring WHAT

Increased daily function Improved test performance Reduced risk of dementia Decreased rate of cognitive decline

(preventing dementia?) Changes in the brain

– Cerebral changes (regions used)– Increased dendritic networks and– Nerve growth– Neurochemical changes

Professional Literature: Measuring WHO

Normal community-dwelling elderly

Normal but “limited” or “at-risk” elderly

MCI elderly Demented elderly

Professional Literature: Measuring HOW

Level, type or frequency of cognitive activity by self-report or observation

Type and frequency of physical activity by self-report

Train improved memory and organizational skills

Train increased mental flexibility Educate about memory, aging, and

coping Measure or facilitate level of social

activity

Positive emotional expression predicts longevity Danner, Deborah D., Snowdon,

David & Friesen, Wallace (2001)The Nun Study

180 nuns, age/educationcorrected ages 75-95 measured expressed emotion in

autobiographies written just prior to taking final vows

Lower linguistic ability in early life predicts dementia and earlier deathSnowdon, Greiner, & Markesberry, 2000: The Nun Study 74 nuns ages 74- 97 measured idea density in

autobiographies looked at ratio of idea density

to neurofibrillary tange counts idea density unrelated to

vascular changes in brain

Engaged Lifestyle: Participation in mentally challenging activities predicts higher cognitive scores (Lahar, 2000)

Used WAIS-R Vocabulary, Digit Span, Boston Naming Test

Compared cognition to self-report of everyday activities

TV Viewing related to lower verbal skills in all age group

Demonstrated relationship between activity and cognition in younger (under 49) but not older (over 50)

Engaged Lifestyle: The Victoria Longitudinal StudyHultsch, Hertzog, Small & Dixon, 1999 250 adults followed over six years Generally high functioning/well

educated Measured:

– Cognitive status on standardized tests– Activity level (both cognitive and

physical)– Self-reported health– Personality (NEO)

Victoria Longitudinal Study: Results

No relationship between:– Self-reported health and cognition– Personality and cognitive status– “active lifestyle” and cognition

Supports relationship between novel tasks and cognition (working memory)

Alternative interpretation: High-ability adults lead intellectually active lives

WW II Veterans: Gold et al, 1995 WWII Veterans tested twice

over a 40 year period Higher intellect, better

education, and higher SES lead to a more engaged lifestyle

Concluded that engaged lifestyle then contributes to maintenance of verbal intellect

Seattle Longitudinal StudySchaie et al

Begun in 1956 by K. Warner Schaie; since 1981 at Penn State with wife Sherry Willis

Now over 5000 adults followed every seven years

Both longitudinal data on intellectual change over time and cross-sectional work on intellectual training

Adult Intellectual Development: the Seattle Longitudinal Study

Seattle Longitudinal Study

Cognitive training on spatial orientation and inductive reasoning tasks

5 hour individual training Found improvement on both

domains and less than average decline in inductive reasoning at seven year follow-up

Seattle Longitudinal Study

Observations on better cognitive outcome in old age– Absence of chronic disease– Complex and intellectual stimulating

environment throughout life– Flexible personality style– High intellectual status of spouse– Persisting high perceptual

processing speed

MacArthur Foundation Study

1200 participants Ages 70 – 80 Followed for 10 years Better cognitive status predicted

by:– Mental activity– Physical activity– Ongoing sense of meaning and

contribution to community

Complex Work Improves Intellectual Function

Schooler, Mulatu, & Oates (1999) Extended a longitudinal study by

Kohn & Schooler of 1983 Original sample of 3101 men 687 re-interviewed in 1974 334 again interviewed in 1994/1995 Showed a positive effect of more

challenging work on intellect, especially for older workers

Cognitively Stimulating Activities Reduce Risk of Alzheimer’s Disease

Wilson, Mendes de Leon, Barnes, Schneider, Bienias, Evans, and Bennett (2002)

801 Catholic nuns, priests, and brothers

Followed from 1994 to 2001 Ratings of frequency on 7 common

activities Ratings of physical activity Neuropsychological testing

Results: Higher cognitive activity associated with

higher baseline cognitive function Ongoing cognitive activity associated with

less decline in working memory and less decline in perceptual speed

Controlling for age, education, and gender:– Lower level of cognitive activity predicted

faster cognitive decline– Risk of developing Alzheimer’s disease

decreased by 33% for each additional point of reported cognitive activity

Professional Literature: Training Programs for Improved Cognition

Learning Mnemonic Strategies Yesavage, Sheikh, Friedman, & Tanke,

1990 218 community dwelling elderly Mean age of 67, range 55 – 87 Four 2 hour sessions of face-name

association and list-learning strategies Variety of one-week pretraining

(imagery, relaxation, or imagery plus judgment)

Learning Mnemonic Strategies: Results of Yesavage et al Both age and MMSE scores

related to post-test performance No difference in type of pre-

training on post-test performance Over age 75 had difficulty learning

the list-learning mnemonic and performed poorer on both tasks

Post test at the end of two week training; no follow-up

Face-Name Recall Training in Dementia

Lars, Staffan, Herlitz, Stigsdotter, & Tiitanen, 1991

8 patients with dementia (7 AD, 1 MID)

Eight training sessions over two weeks

Immediate and one month follow-up No improvement from baseline to

immediate f/u on 7 patients; one did improve

Meta-analysis of Memory Training in Normal Elderly

Verhaeghen, Marcoen, & Goossens, 1992

31 research studies reviewed Retesting alone enhances memory

performance on standardized tests

Memory training improves performance

Training gains are specific to training (poor generalizability)

Verhaeghen, et al Meta-analysis

Treatment gains in Memory training were largest:– In group training rather than

individual–With younger participants– In shorter training sessions

(less than 1.5 hours)–When pre-training was provided

Longer-term Memory Training Oswald, Rupprecht, Gunzelmann, &

Tritt, 1995 375 people aged 75 – 89 272 treatment group, 103 controls Baseline, end-treatment, and one yr f/u Weekly intervention group over 30

weeks Training on:

– Coping strategies– Memory Training– Psychomotor Training

Results: 30 week Memory Training

Memory groups improved memory test performance

Coping strategy group improved everyday competence

Best outcome was for combined psychomotor and memory training

One yr f/u showed persisting effects of initial changes but overall performance decrements

Longer-term vs. Shorter Memory Training Woolverton, Scogin, Shackelford,

Black, & Duke, 2001 77 participants –community

dwelling elderly Aged 60 – 88 Self-paced instructional manuals 24 day one-hour study sessions 13 day shorter training geared to 3

targeted memory areas: names, locations of objects, dates and appointments

Longer-term vs. Shorter Memory Training: Results

Group overall demonstrated improved performance in memory strategy use

The 24 session group proved much more effective at memory strategy use and in improving performance on objective memory measures

Shorter group had no demonstrable changes in targeted memory areas

Knowledge of Memory and Everyday Function Improves with Education

Troyer (2001) 36 participants and 24 controls Five weekly 2-hour sessions on

– Normal aging– Memory processes– Reducing risk of dementia– Healthy lifestyle issues– Everyday memory strategies– Practice assignments between meetings

Troyer Results: Greater pretest to post-test

change scores on reports of everyday memory function

Increased knowledge of how memory works

Better performance on a prospective memory task

No change in list learning or name recall tasks

ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly)

Began enrollment in 1998 Multi-center study (UAB, Boston,

Indiana University, Johns Hopkins, Penn State)

2832 participants over the age of 65

No evidence of cognitive, physical or functional decline

10 training sessions plus four “booster session 11 months later

ACTIVE Randomized to four groups:

– Memory Training– Reasoning Training– Speed Training– Control Group

Measures of cognition, everyday function by self-report, paper and pencil, and observation

Quality of Life, health service utilization, everyday mobility

Memory Training Caveats Memory training seems to have

minimal effect on subjective measures of memory dysfunction (Floyd & Scogin, 1997)

Memory training does not typically address memory problems most elders complain about (Leirer, Morrow, Sheikh, Pariante, 1990; Yesavage, Lapp, & Sheikh, 1989)

Memory strategies require lots of effort and are seldom used outside of clinical training sessions (Park, Smith, & Cavanaugh, 1990)

Increasing Complex Cognitive Activity Later in Life might: Increase sense of purpose, motivation, and

hope Decrease depression Improve level of socialization Offer additional outlets for emotional

expression Decrease stress and improve coping Improve use of compensatory strategies Increase depth of processing Increase level of physical activity Increase engagement with good “role

models”

Research Outcomes Normal elderly can improve on

cognitive tests with training Memory training shows minimal to

no impact on subjective memory complaints or everyday function

Lifelong cognitive activity may minimize risk of cognitive impairment

No documentation that training activity leads to changes in brain

Research Outcomes Education on memory, healthy lifestyle,

and compensatory strategies can improve subjective memory and prospective memory

Unclear if increased mental activity late in life can affect cognitive status or stave off dementia

No documented association between– “mind games” and improved everyday

function– “mind games” and decreased risk of dementia

Final Observations Keep what you’ve got rather than

try to get back what you’ve lost Be social active—enhances both

emotions and cognitions Engage in novel real-life mental

activity throughout life Our emphasis should be on

activity/behavior that reduces disability and improves everyday function