The Healthy Brain Initiative - Alzheimer's Disease and ... The Healthy Brain Initiative: A National...
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The Healthy Brain InitiativeA National Public Health Road Map to Maintaining Cognitive Health
Acknowledgements
Executive Summary 1
I Background 4 Whatiscognitivehealth? 5 WhyprepareaRoadMap? 7 Whyisitimportant—andwhynow? 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
TheHealthyBrainInitiative:A National Public Health Road Map to Maintaining Cognitive Health
TableofContents
Suggested Citation: CentersforDiseaseControlandPreventionandtheAlzheimer’sAssociation.TheHealthyBrainInitiative:ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth:Chicago,IL:Alzheimer’sAssociation;2007
Availableatwww.cdc.gov/agingandwww.alz.org
Centers for Disease Control and Prevention and the Alzheimer’s Association
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Acknowledgements
WethankthemembersoftheSteeringCommitteeforgivingcountlesshourstothinkaboutanddiscussthisNational Public Health Road Map to Maintaining Cognitive Health;theircontributionshavebeeninvaluable.
LyndaAnderson,PhD(Cochair)Centers for Disease Control and Prevention
StephenMcConnell,PhD(Cochair)Alzheimer’s Association
FrankBailey,JDAARP
WilliamF.BensonHealth Benefits ABC’s
DebraCherry,PhDAlzheimer’s Association
GregCaseAdministration on Aging
HughC.Hendrie,MB,ChB,DScIndiana University Center for Aging Research Regenstrief Institute, Inc.
JamesLaditka,DA,PhD,MPAUniversity of South Carolina
DebraLappin,JDB&D Consulting LLC
MarcelleMorrison-Bogorad,PhDNational Institute on Aging
PeterRabins,MD,MPHJohns Hopkins University School of Medicine
RamonaL.Rusinak,RN,PhDArizona Department of Health Services
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ExecutiveSummary
InFall2005,theCentersforDiseaseControlandPreventionandtheAlzheimer’sAssociationformedanewpartnership
toexaminehowbesttobringapublichealthperspectivetothepromotionofcognitivehealth.ToassistwiththisHealthyBrainInitiative,thePartnersworkedcloselywiththeNationalInstituteonAgingandtheAdministrationonAgingtoconveneamultidisciplinarySteeringCommitteeandanevenwiderarrayofinvitedexpertsfromconcernedpublicandprivatesectororganizations.Togetherweexaminedthecurrentstateofknowledgeregardingthepromotionandprotectionofcognitivehealth,identifiedimportantknowledgegaps,anddefinedtheuniqueroleandcontributionsofpublichealth.Wefocusedonvascularriskfactorsandphysicalactivitybecauseoftheirassociationwithcognitiveoutcomes,adoptedastrategicframework,andembarkedonanintensiveprocesstogeneratetheactionsofferedinthis National Public Health Road Map to Maintaining Cognitive Health.
TheRoadMaprecognizescurrentsocialtrendsandotherfactorsthataffectcognitivehealthfromapublichealthstandpoint:anagingpopulation,growingfearandconcernexpressedbymanypeopleastheyageabouttheirpotentiallossofcognitivefunction,increasingsocietalburdenfromcognitivedecline,greatercaregiverburden,andacontinuedlackofawarenessaboutcognitivehealthamongconsumersandprovidersalike.
Withthisbackdrop,weofferaloftybutachievablelong-termgoal:
To maintain or improve the cognitive performance of all adults.
Toaccomplishthisgoal,weproposeasetof44actionsthatarefirmlygroundedinscience,emphasizeprimaryprevention,assumeacommunityandpopulationapproach,andarecommittedtoeliminatingdisparitiesinpersonalhealthandhealthcareforracialorethnicgroups.Itiscriticaltonotethateachpriorityactionisbasedonadetailed,scientificrationale,withimplementationtobebasedondemonstratedeffectivenessofspecificinterventions.TheseactionsshouldthereforebeconsideredinthecontextoftherationalespresentedinSectionVoftheRoadMap.Withinthefullsetofactionsare10prioritiesworthyofimmediateattention:
ExecutiveSummary
• Determinehowdiverseaudiencesthinkaboutcognitivehealthanditsassociationswithlifestylefactors.
• Disseminatethelatestsciencetoincreasepublicunderstandingofcognitivehealthandtodispelcommonmisconceptions.
• Helppeopleunderstandtheconnectionbetweenriskandprotectivefactorsandcognitivehealth.
• Conductsystematicliteraturereviewsonproposedriskfactors(vascularriskandphysicalinactivity)andrelatedinterventionsforrelationshipswithcognitivehealth,harms,gapsandeffectiveness.
• Conductcontrolledclinicaltrialstodeterminetheeffectofreducingvascularriskfactorsonloweringtheriskofcognitivedeclineandimprovingcognitivefunction.
• Conductcontrolledclinicaltrialstodeterminetheeffectofphysicalactivityonreducingtheriskofcognitivedeclineandimprovingcognitivefunction.
• Conductresearchonotherareaspotentiallyaffectingcognitivehealthsuchasnutrition,mentalactivity,andsocialengagement.
• Developapopulation-basedsurveillancesystemwithlongitudinalfollow-upthatisdedicatedtomeasuringthepublichealthburdenofcognitiveimpairmentintheUnitedStates.
• Initiatepolicychangesatthefederal,state,andlocallevelstopromotecognitivehealthbyengagingpublicofficials.
• IncludecognitivehealthinHealthy People 2020,asetofhealthobjectivesforthenationthatwillserveasthefoundationforstateandcommunitypublichealthplans.
Itisourhopethatthese10priorityactionswillservetofocusthenation’sresourcesonaddressingriskandprotectivefactorsforpromotingcognitivehealthoverthenext3-5years.Asalivingandflexibledocument,theRoadMaprepresentsbothacalltoactionandaguideforimplementinganeffectivecoordinatedapproachtomovingcognitivehealthintopublichealthpractice.Thekeytosuccessliesincontinuingandexpandingresearch;developingandchannelingresources;workingtodeveloporstrengthenpartnershipswithlike-mindedorganizations;designingcollaborativeoperationalplansofaction;andestablishingsystemstotrackprogress,facilitatecommunication,andexchangeinformation.
Continuedvigilanceonthisissue,andtimelytranslationofresearchfindingsintocommunityaction,willassurethatwereapthepotentialrewardsthatpublichealthcanofferinimprovingqualityoflifeamongadultsandreducingsocietalcostsforhealthcareandotherservices.
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What is cognitive health?
Thedistinctionbetweenthemindandbodywasaconceptfirstformallysetforthinthe17thcenturybyphilosopherReneDescartes.Overthenextseveralcenturies,thebodywasseenastheconcernofphysicians,whilethemindwasthepurviewoforganizedreligion.1
Overtheyears,ourunderstandingof“bodyandmind”hasevolvedsignificantly.Wenowrecognizethevitalrolethatbothphysicalhealthandmentalhealthplayinshapingouroverallwell-being,andweappreciatethevaluablecontributionsthatawidearrayofhealthprofessionscanmaketowardassuringthatwell-being.
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IVdevelopment
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Mentalhealthencompassesemotionalfunctioningandtheabilitytothink,reason,andremember(cognitivefunctioning).Whilestandardized,widelyaccepteddefinitionsofcognitive healthhaveyettobeadopted,mostexpertsagreethatthecomponentsofhealthycognitive functioning include:
• language• thought• memory• executivefunction(theabilitytoplanandcarryouttasks)• judgment• attention• perception• rememberedskills(suchasdriving)• abilitytoliveapurposefullife2
Muchlikephysicalhealth,cognitivehealthcanbeviewedalongacontinuum—fromoptimalfunctioningtomildcognitiveimpairmenttoseveredementia.ItisnotsimplytheabsenceofdiseasessuchasAlzheimer’sdisease;rather,itshouldberespectedforitsmultidimensionalnature,andthechangesthattakeplaceoverthelifespanshouldbeaccepted,evenembraced,asanaturalpartoftheagingprocess.3
Cognitivedeclinecanrangefrommildcognitiveimpairmenttodementia,butthesetwoconditionsarenotnecessarilymanifestationsofthesamedisease.Manypeopleneverdevelopanyseriousdeclineintheircognitiveperformance,andthosewhodevelopmildcognitiveproblemsdonotnecessarilydevelopdementia.Althoughnotallpeoplewithcognitivedeclinedevelopdementia,thosewithanamnesticformofmildcognitiveimpairmentdohaveamuchhigherriskfordementiathanotheradults.
Thelackofcognitivehealthcanhaveprofoundimplicationsforaperson’sphysicalhealth.Olderadultsandothersexperiencingcognitiveimpairmentmaybeunabletocareforthemselvesortoengageinnecessaryactivitiesofdailyliving,suchaspreparingmealsormanagingtheirfinances.Limitationsintheabilitytoeffectivelymanagemedicationsandexistingmedicalconditionsareofparticularconcernwhenapersonisexperiencingcognitiveimpairmentordementia.
Dementiaaffectsaperson’sabilitytocomprehendandactonmessages,andinvolvesproblemswithmemory,understandingorusingwords,andidentifyingobjects.Thesignificantlyimpairedcognitionassociatedwithdementialeadstoalossofsenseofselfandoflifelongmemories;adecreasingabilityto
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copewiththenormaldemandsofliving;problemsaccessinghealthcaresystems;greatervulnerabilitytodisease,injury,malnutrition,crime,andpossiblyabuse;andeventuallyalossofindependence.Thatlossofindependencebecomesaburdenonfamiliesandsociety,astheindividualrequiresmoreintensecareandofteninstitutionalization.Inthelaterstages,thecognitiveimpairmentassociatedwithdementiawillcreatetotaldependency,andAlzheimer’sdiseaseisnowrankedasthe8th-leadingcauseofdeath.5
Why prepare a Road Map?
Bringingapublichealthperspectivetocognitivehealthrequiresaninclusiveandstrategicapproach.Muchimportantworkhasalreadybegun,initiatedandsponsoredbyavarietyoforganizationsandagenciesatnational,state,andlocallevels(seepages10-11forasamplingofcurrentefforts).
“Mostimportanttoourabilitytoliveourliveswellisthecombinationofmentalprocesseswecall‘cognition’or‘knowing.’Thiscombinationincludestheabilitytolearnnewthings,intuition,judgment,language,andremembering.Havingaclear,activemindatanyageisimportant,butaswegetolderitcanmeanthedifferencebetweendependenceandindependentliving.”4
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Oneoftheselandmarkefforts,theNationalInstitutesofHealth(NIH)CognitiveandEmotionalHealthProject(CEHP),wasofficiallylaunchedin2001.SelectedexpertsfromseveraluniversitiesandtheNIHcriticallyanalyzedthescientificliteraturetoidentifypossibleriskandprotectivefactorsformaintainingcognitiveandemotionalhealthinadults.6Inrecognitionoftheimportanceofthiseffort,andasfurthertestamenttotheincreasedvisibilitythatcognitivehealthisreceiving,Congressappropriatedfundsinfiscalyear2005totheCentersforDiseaseControlandPrevention(CDC)toaddresscognitivehealthwithafocusonlifestyleissues.Withthissupport,CDCformedapartnershipwiththeAlzheimer’sAssociationandisworkingcloselywiththeNationalInstituteonAging,theAdministrationonAging,andotherpublicandprivatesectororganizationsonaHealthyBrainInitiative.
Thispartnership:
• FormedaSteeringCommitteemadeupofnationalexpertstoprovideoverallguidanceandcoordinationfortheInitiative(AppendixA).
• ConvenedaPublicHealthResearchWorkingGroupMeetinginMay2006onThe Healthy Brain and Our Aging Population: Translating Science to Public Health Practice.During
this2-dayinvitationalmeeting,nationalexpertsreviewedresearchinpublichealthpreventionrelatedtobrainhealth,anddiscussedspecificrecommendationsforaddressingriskandprotectivefactorsforpromotingcognitivehealth.Theyfocusedonvascularriskfactorsandphysicalactivitybecauseoftheirassociationwithcognitiveoutcomes.
ThefindingsfromthisresearchmeetingprovidedafoundationandcommonframeofreferenceforthenextstepoftheHealthyBrainInitiative:developingstrategicpublichealthrecommen-dations.Forthistask,thePartnershipformedworkgroupsinfourareasofpublichealthaction:PreventionResearch,Communication,Surveillance,andPolicy.Eachworkgroupwaschargedwithdraftingrecommendationsformovingthenationforwardoverthenext3-5yearstowardthelong-termgoalofmaintainingandimprovingthecognitivefunctionofadults.Keystakeholdersatthenational,state,andlocallevelsthenrefinedtherecommendationsandselectedthoseofhighestpriority(AppendixA).
TheNational Public Health Road Map to Maintaining Cognitive Healthreflectstheculminationofthis18-monthprocess.AsacornerstoneoftheInitiative,itoffersapathforhowwecanlearnmoreaboutcognitivehealthandthenultimately
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translatewhatwelearnintoreal-worldpracticetoimprovethehealthofallAmericans.
TheauthorsoftheRoadMaprecognizethatinthecourseofdailylifethedomainsofemotionalandcognitivehealthareinextricablylinkedandcannottrulybeseparated.ForthisRoadMap,however,weassumethisdistinctionandfocussolelyoncognitivehealth.Onlyrecentlyhavepublichealthexpertiseandresourcesbeenrecognizedforaddressingcognitivehealth.TheRoadMapreflectsacommitmenttobringtheareaofcognitivehealth“uptopar”withemotionalhealthastreatmentsandpreventivestrategiesbecomeavailable.Itisthefirststepinasystematicprocessforbringingcognitiveandemotionalhealthtogetherinamorecomprehensiveandcoordinatedpublichealthapproach.
“Wearebeginningtotakethenextsteps,buildingontheresearchcomingoutofNIHandothers,andmovingwhatweknowoutintocommunitypractice.ThisiswherewecanmakeadifferenceintheeverydaylivesofAmericans.”LyndaA.Anderson,PhDHealthy Aging Program, Centers for Disease Control and Prevention
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Background
A Sampling of Current Efforts
Pursuing Research on Factors Influencing Cognitive Health
TheNationalInstitutesofHealth(NIH)isfundingongoingresearchtoclarifytherelationshipamongminimizingvascularriskfactors,exercise,otherlifestyleanddruginterventions,andcognitivehealthstatus.Epidemiologicstudiesareidentifyinglikelyriskandprotectivefactors;thesearebeingtestedinanimalstudies,whichalsocanhelpidentifythemechanismsbywhichriskandprotectivefactorsmightwork.Inordertoconfirmthattheencouraginginterventionsidentifiedinepidemiologyandanimalstudiescouldactuallymaintaincognitivehealthifappliedtohumans,clinicaltrialsmustbecarriedout.Somearealreadyinprogressbutothersarestillonlyintheplanningphase.NIHkeepsthepublicup-to-dateonthecurrentstateofthesciencethroughoperationofaWebsiteandanationalclearinghouse.
Assessing Public Perceptions
Formativeresearchwithdiversegroupsisrequiredtohelpgainunderstandingonthepublic’sperceptionsaboutcognitivehealth.OnesucheffortiscurrentlyunderwaywiththesupportofCDC.TheHealthyAgingResearchNetwork,withinitslargerPreventionResearchCentersProgram(PRC-HAN),conductspreventionresearchonavarietyofhealthissuesinvolvingolderadults.WithinthePRC-HAN,membersarecollaboratingonaseriesoffocusgroupsdesignedtoidentifyhowdiversegroupsofolderadultsunderstandcognitivehealthandwhatapproachestohealthpromotionanddiseasepreventionrelatedtobrainhealththepublicmayfindmostappealing.Thisprojecthasrecentlybeenexpandedtoexaminetheperceptionsofcaregiversandhealthcareproviders.Itwillprovideimportantdatathatcanbeaddedtowhatisalreadyknownaboutcognitiveorbrainhealth,identifygapsinknowledgeaboutcognitivehealthandrelatedriskfactors,anddeterminewhethersuchbeliefsvaryacrossgeographicaldistancesandbetweendiversepopulations.Finally,thisworkisdesignedtoleadtothedevelopmentandtestingofashortsetofquestionsthatcanbeusedtoassessthepublic’sandpossiblyproviders’perceptionsaboutcognitivehealthforinclusioninongoingnationalattitudinalsurveys.
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Conducting Community Education Programs
TheAlzheimer’sAssociationhasrecentlylauncheda5-yearcommunity-baseddemonstrationprojecttopromoteabrain-healthylifestyle.ThecommunityinterventionisdesignedtoaffectknowledgeandattitudesamongAfricanAmericanbabyboomersrelatedtophysicalactivityandvascularriskfactors,anditwillbeoverlaidwithothergeneralhealthbehaviorssuchasdiet,socialactivity,andmentalactivity.Duringthefirstphaseofthisproject,theAlzheimer’sAssociationisleadingacomprehensiveinterventionplanninganddevelopmenteffort,includingformativeresearchtoassesscurrentneedsandobstaclesforthetargetpopulation,elicitingcommunityinputandparticipation,andcreatingacomprehensive,multilevelcommunityinterventionwithrobustevaluationmechanismstomeasuretheeffectivenessofthepublichealthprograminitsnextphase.
Developing Common Measures of Cognitive Decline for Surveillance and Research
TheNationalInstitutesofHealthisleadinganinitiativetodevelopunifiedandintegratedmethodsandmeasuresofcognitive,emotional,motor,andsensoryhealthforuseinlargecohortstudiesandclinicaltrials.Researchershaveexpressedtheneedforbriefassessmenttoolsthatcouldbeusedasaformof“commoncurrency”acrossdiversestudydesignsandpopulations.Thisinitiativewilltakeadvantageofstate-of-the-artpsychometricresearchandnoveltestingmethodstodevelopaninnovativeapproachtoneurologicalandbehavioralhealthmeasurement.Ultimately,itishopedthatthisapproachwillrespondtotheneedsofresearchersinavarietyofsettings,withparticularemphasisonmeasuringoutcomesinlargelongitudinalandepidemiologicstudiesandpreventionorinterventiontrialsacrossthelifespan.Withanavailabletoolboxofmeasures,yieldsfromlargeandveryexpensivestudiescanbemaximizedbyallowingamuchlargernumberofimportantresearchquestionsregardingneurologicalandbehavioralhealthtobestudied.Byensuringthattheassessmentmethodsarecapableofcomparisontoexistingandcompletedstudiesandcanincorporatefuturemodifications,atruly“economic”andvaluablenationalresourcefortheentireneurosciencecommunitywillresult.
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Why is it important—and why now?
TheNational Public Health Road Map to Maintaining Cognitive Healthcomesatacriticaltime,giventhedramaticagingoftheU.S.population,thegrowingscientificinterestintheroleoflifestylestrategiesinmaintainingcognitivefunction,andincreasingawarenessofthesignificanthealth,social,andeconomicburdensassociatedwithcognitivedecline.
An aging population Ageisariskfactorforcognitivedecline.In2004,oneineveryeightAmericans—36.3million—wereaged65yearsorolder.By2030,thisnumberisexpectedtonearlydoubleto71.5million.Atthattime,20%ofthepopulationwillbeinthisagegroup.7
Growing fear and concern about memory loss ThereisconsiderableconcernamongAmericansaboutthelossofcognitivehealthtodiseaseordisability,8aconcernthatseemstoincreasewithage.Mostolderadultslookforwardtohavingalonglife,andyettheirgreatestworriesaboutlivingtoage75revolvearoundmemoryloss.9Accordingtoarecentsurvey,adultsaremorethantwiceaslikelytofearlosingtheirmentalcapacity(62%)astheirphysicalability(29%).10
Increasing burden from cognitive decline IntheUnitedStates,thesocietalburdenofcognitiveimpairmenthasbeenexpressedmainlyintermsofprevalence,incidence,andmortalityfordementiagenerallyorforAlzheimer’sdiseaseinparticular.Morerecently,prevalencestatisticsfor“mildcognitiveimpairment”or“cognitiveimpairmentnodementia”havealsoappeared.Cognitiveimpairmentnodementiareferstoalevelofcognitiveimpairmentthatismoreseriousthanage-relatedcognitiveimpairment,butitisnotassevereasAlzheimer’sdiseaseorotherformsofdementia.
• Alzheimer’sdiseasehasbeeninthetoptenleadingcausesofdeathsincethe20thcentury.11Notably,themortalityratesforAlzheimer’sdiseaseareontherise—incontrasttotheratesforheartdiseaseandcancer,whicharecontinuingtodecline.12
• Anestimated4.5millionAmericanshaveAlzheimer’sdisease.Thatnumberhasdoubledsince1980,andisexpectedtobeashighas16millionby2050.13
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• StudiesfromtheUnitedStatesandCanadahavesuggestedthatmildcognitiveimpairmentorcognitiveimpairmentnodementiamaybeaproblemfor16-25%oftheelderlypopulation(65andolder).14,15,16
• In2005,MedicareandMedicaidspent$91billionand$21billion,respectively,forpersonswithAlzheimer’sdisease.17Accordingtoa2004reportthatanalyzedMedicareclaimsdata,olderbeneficiarieswithdementiacostMedicarethreetimesmorethanotherolderbeneficiaries.18Basedoncurrentestimates,thesecostswilldoubleevery10years.19
Caregiver burden Maintainingcognitivehealthcanmeanthedifferencebetweenlivingindependentlyorfacingtheneedforfamilyorinstitutionalcare.Theburdenofcognitivedeclineoncaregiversisenormous.ThenumberofcaregiversintheUnitedStatesin2003wasestimatedtobe44.4million20andthisnumberisexpectedtorisedramaticallywiththeagingof
“Thenewsciencehasshiftedthefocustotheideathatthereisvalueinapublichealthstrategyofgettingpeopletothinkabouttheirbrainandhowtheymightaltertheirbehaviortokeeptheirbrainhealthy.”StephenMcConnell,PhDAlzheimer’s Association
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thepopulation.Thecostsofunpaid,informalcareprovidedbyfamilieshavebeenshowntoaccountforalargeproportionofthecostsoftreatingdementiaandtheyincreasesharplyasthepatient’scognitiveimpairmentworsens.21Therearealsophysicalandmentalcostsassociatedwithcaregiving;inonestudy,nearly43%ofthefamilymembersprovidingcaretorelativeswithdementiahadclinicallysignificantlevelsofdepressionduringthelastfewmonthsofthepatient’slife.22Numerousfactorsmakeprovidingcareforpersonswithseveredementiaemotionallyandphysicallychallenging;abetterunderstandingofthesefactorswillaidinthedesignofstrategiesthatsupportthehealthandwell-beingofcaregivers.
Underlying lack of information about what is known about brain health Manyadultsappeartobelievethatagingisatimeofirreversiblementaldecline,andthatdementiaisuniversalandinevitable.Thesemythspersistseventhoughrecentresearchhasshownthatinthehealthyagingbrain,newsynapsescontinuetoformandnervecellscanregenerate.23
Yet,thereareemergingsignsthatAmericanslooktothefuturewithhope.Basedonseveralsurveys,menandwomeninthiscountryarewillingtotakeimportantstepstoimprovetheircognitivehealth.
• Nearly9of10peoplereportedthattheythoughtitispossibletoimprovecognitivefitness.24
• Sixof10statedthattheyfelttheyshouldhavetheircognitivehealthcheckedroutinely,muchlikearegularphysicalcheckup.25
• Morethan8of10(84%)reportedthattheytooksometimenearlyeverydaytoengageinactivitiesthatmaybeassociatedwithimprovedcognitivehealth:engaginginartorcreativeprojects,reading,keepingphysicallyactive,playinggamesordoingpuzzles,working,orspendingtimewithfamilyandfriends.26
• OverhalfanticipatedamajormedicalbreakthroughindiscoveringacureforAlzheimer’sdiseasewithinthenext20years.27
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Giventhetremendousburdensdescribed,theirimpact,andthedevelopingscience,publichealthshouldstepforwardtoaddresscognitivehealth.Thepotentialcontributiontoqualityoflife,thepositiveimpactoncaregivers,andtheanticipatedsavingsinthecostsofhealthcareandotherserviceswouldbeconsiderable.28,29,30,31
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State of KnowledgeWhat do we know?
InMay2006,CDCandtheAlzheimer’sAssociationinvitednationalexpertstoreviewresearchonpublichealthpreventionrelatedtocognitivehealth,andtoidentifyspecificrecommendationsforaddressingriskfactorsthatpromoteandprotectcognitivehealth.Duringthismeeting,participantsexaminedthecurrentstateofscienceconcerningmajorrisk
factors,including:a)riskfactorsforvasculardiseaseandb)physicalinactivity,andtheylookedatcurrentmodelsformovingscienceintopublichealthpractice.Participantsfocusedonthesefactorsbecauseoftheirassociationwithcognitiveoutcomes.32Theyconcludedthatresearchsuggeststhefollowingfactorsmaybeassociatedwiththemaintenanceofcognitivehealth:1)preventingorcontrollinghighblood
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pressure,cholesterol,diabetes,overweight,andobesity;2)preventingorstoppingsmoking;and3)beingphysicallyactive.33
Severalspecificobservationswerenotedbymeetingparticipantsregardingtheassociationsbetweenvascularriskfactorsandphysicalinactivityandcognition.
• Evidenceexiststoindicatethatcumulativerisksforvasculardiseaseincreasetheriskforstrokeandcognitivedecline.
• Sufficientevidencealsoexiststosupporttheassociationbetweenvascularhealthandcognitivehealth,althoughclinicaltrialsarenecessarytoestablishtheeffectivenessofinterventionstargetedtovascularriskfactors.
• Itisimportanttoemphasizethatcontrollingvascularriskfactorsisassociatedwithreductioninanindividual’sriskofcognitiveproblems,butcurrentsciencedoesnotsupporttherelationshipbetweencontrollingvascularriskfactorsandimprovedcognitivefunction.
• Growingevidenceexiststhatphysicalactivitymaymaintainorimprovesomeaspectsofcognitivefunctionintheshortterm,butfurtherresearchisneededbothtodeterminelong
termoutcomesandthenatureofrecommendations(e.g.,theamountofphysicalactivity).
• Strongevidenceexiststosupporttherelationshipbetweenphysicalactivityandemotionalwell-being.
WhilenotaspecificfocusoftheMayresearchmeeting,additionalfactorsthatmaybeassociatedwithmaintainingcognitivefunctionincludesocialengagement,a“heart-healthy”diet,andemotionalsupports.Inaddition,higherhouseholdandcommunitysocioeconomiclevelsinearlylifeareassociatedwithhigherlevelsofcognitioninlatelifebutnotwiththeriskofAlzheimer’sdiseaseorrateofcognitivedecline.34
What gaps exist?
Eachnewdiscoveryinmaintainingcognitivehealthraisesahostofimportantquestions.Someofthemorepressingissuesarethefollowing:
• Howdowepromotetheimportanceofcognitivehealthissuestokeyconstituenciesandstakeholders?
• Whatarethepublic’sperspectivesonlifestylebehaviors,choices,andattitudesconcerningcognitivehealthandtheburdenofcognitivedecline?Whatdoweviewasthebenefits
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andbarriersofmodifyingpersonallifestyletoreducetherisksassociatedwithcognitivedecline?
• Whatistheroleofpopulation-basedsurveillanceandtheappropriatesurveillancesystemstoassesscognitivedecline?
• Whatclinicaltrialsandotherresearchareneededtodeterminethelong-termoutcomesoflifestyleinterventionsonparticularcognitivefunctions?
• Howdowelinkscientificallyvalidmessagesaboutriskofcognitivedeclinetocurrentpublichealthmessagesforeffortsinprimaryprevention?
• Whataretheeffectsofmodifyingmultipleriskfactorsonminimizingcognitivedeclineorimprovingcognitivefunction?
How can public health contribute?
Publichealthwasfirstdefinedin1926,as“thescienceandartofpreventingdisease,prolonginglifeandpromotinghealthandefficiencythroughorganizedcommunityeffort.”35Thatdefinitionhasremainedintactforover80years,witharecentreiterationofpublichealth’smissionas“assuringconditionsinwhichpeoplecanbehealthy.”36
Organizedpublichealtheffortsoverthepast100yearshaveyieldedremarkableachievements.Tenconsideredtobeamongthegreatest37areintheareasof:
• Vaccination• Motor-vehiclesafety• Saferworkplaces• Controlofinfectiousdiseases• Declineindeathsfromcoronaryheartdisease andstroke
“Allthethingsthatweknowarebadforyourheartturnouttobebadforyourbrain.”MarilynS.Albert,PhDJohns Hopkins Medical Institutions
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• Saferandhealthierfoods• Healthiermothersandbabies• Familyplanning• Fluoridationofdrinkingwater• Recognitionoftobaccouseasahealthhazard
Theseachievementswerepossiblebecauseofcombined,coordinatedeffortstoapplythreecorepublichealthfunctions:assessment,policydevelopment,andassurance.
Assessmentcallsforregularlyandsystematicallycollecting,analyzing,andsharinginformationonthehealthofacommunity.Suchinformationhelpstodescribeandunderstandacommunity’shealthstatusandneeds.Assessmentactivitiesmightinvolveinvestigatingadversehealtheffectsandhealthhazardstoidentifythemagnitudeofahealthproblem,itslocation,trendsovertime,andpopulationsatrisk.Theymayalso“digdeeper”toanalyzedeterminantsofidentifiedhealthproblemssoastoilluminateetiologicandcontributingfactorsthatplacecertainpopulationgroupsatriskforadversehealthoutcomes.
Policy developmententailspromotionofpublichealthpoliciesthataregroundedinscience-baseddecisionmaking.Bytakingtheleadinpolicydevelopment,publichealthserves
asanadvocate,buildsconstituencies,andidentifiesresourcesinacommunityasitgeneratessupportiveandcollaborativerelationshipswithpublicandprivateagencies.Anothercriticalpolicyactivityinvolveshelpingcommunitiessetprioritiesamonghealthneedsbasedonthesizeandseriousnessofthehealthproblemsandtheacceptability,economicfeasibility,andeffectivenessofinterventions;thecommunitycanthendevelopplansandpoliciestoaddressthosepriorities.
Assuranceistheguaranteethatservicesneededtoachieveagreed-upongoalsareactuallyprovided.Itispursuedbyencouragingtheactionsofothers(publicorprivate),requiringactionthroughregulation,orbyprovidingservicesdirectly.Thisthirdcorepublichealthfunctionencompassesmanagingresourcesanddevelopingorganizationalstructures;implementingprogramsforpriorityhealthneeds;andevaluatingandprovidingqualityassurancetoensurethatprogramsareconsistentwithplansandpolicies—orthatneededcorrectiveactionsaretakenpromptly.Inaddition,assuranceactivitieshelptoinformandeducatethepubliconhealthissuesofconcern;promoteawarenessofpublichealthservices;andpromotehealtheducationinitiativesthatcontributetoindividualorcollectivechangesinhealthknowledge,attitudes,andpracticesthatmakeforahealthiercommunity.
StateofKnowledge
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Theapplicationofthesepublichealthfunctionstocognitivehealthoffershopeofsimilarachievementsasscientificknowledgeadvances.Theareaofcognitivehealthisgainingincreasingattentionfrommultipleperspectivesandrepresentsablossomingarenaforresearchandaction.Byembracingcognitivehealthasapriorityissue,thepublichealthcommunitywouldbemobilizedtostudy,identifyandimplementeffectiveinterventionsthatpreservethiskeycomponentofhealth.Ourchallengeistoofferasystematicapproachthatwillassureacoordinatedandunifiednationaleffort.TheRoadMapmeetsthatchallengebylayingoutasharedvisionfora“workinprogress,”onethatbuildsonthefoundationoftheworkdonetodate,establishesaframeworkwithinwhichtoviewthefindingsofthatwork,linksrelatedandcomplementaryactivities,andshapestheworkofthefuture.
“Ifyoucouldgivepeopleinformationandtoolsthatwoulddelaytheonsetofcognitiveimpairmentbyafewyears,youwouldbedoingmuchtoimproveindividuals’qualityoflifeaswellasimprovingsociety.”DebraCherry,PhDAlzheimer’s Association
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Strategic FrameworkWhat is our model for action?
TodeveloptheRoadMap,weuseda“synergistic”model(Figure1)formovingscienceintopublichealthpractice.38Themodelstartswiththeassumptionthatwemustfirstunderstandtheexisting science and knowledge baseforpreservingandprotectingcognitivehealth,determinefindingsreadyto
bemovedintothepublichealtharena,andthenconductresearchtofillimportantgapsinknowledge.
Atthesametime,wemustanalyzesocial and environmental forcesthatcreatedemandandinfluencetheacceptanceofnewknowledge.Thepushofscienceandthepullofthemarketcombinetoshapethecapacity—thecomplementofhumanandfinancialresources—wemusthaveinplacetoimprove
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Figure 139 The Model: Moving Science into Public Health Practice
StrategicFramework
Intermediate Outcomes
Long Range Outcomes
Build and strengthen capacity
(competencies, resources,
partnerships, etc.)
Create/expand the science and knowledge base
Create/sustain social/environmental demand
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“Thepossibilityofpreventioninthisareaissonewandsoexcitingforfamilies,individuals,andgovernment.”JamesLaditka,DA,PhD,MPAUniversity of South Carolina publichealthpractice.Strengtheningandbuildingcapacity
focusesonidentifyingkeypublichealthentities,determiningthenecessarycompetenciesandresources,andexpandingpartnershipstomountandsustainnecessaryactions.Deployingthiscapacityeffectivelywillleadtodesiredintermediate and long-range outcomes.
What principles do we embrace?
Severalkeyprinciplesunderlieourapproachtomaintainingcognitivehealth.
A firm grounding in science. Epidemiologicstudiesfollowedbythetestingofinterventionsinclinicaltrialswithcomponentsthatincludecognitiveassessmentwillshowwhichlifestylefactorsbestmaintaincognitivehealthforthepopulation.Throughpopulation-basedsurveillance,epidemiologyandpreventionresearch,publichealthcancontributetoourunderstandingofcognitivehealthandcanidentifypromisinginterventionsthatmaybeeffectiveinpromotingorprotectingit.TheRoadMaprecognizesthatthisprocessisevolutionary,anditseekstobuilduponwhatwecurrentlyknowbyincorporatingnewdiscoveriesastheyemerge.
An emphasis on primary prevention.Publichealthfocusesonreducingthefactorsthatputpeopleatriskofcognitivedecline,whileincreasingthefactorsthatpromoteandprotectcognitivehealth.Thus,theRoadMapfocusesoninterventionsinhealthpromotionandriskreductionthatpreservecognitiveperformance—ratherthanpreventdementia.Itrecognizesthepotential“synergistic”approachbyintegratingtheseinterventionswithotherlifestylemessagesandshowinghowtheymightfitwithpharmacologicinterventions.
A community and population approach. Publichealthtakesabroadviewandseekstoachievelastingchangeinthehealthofentirepopulations,extendingfarbeyondthemedicaltreatmentofindividualpeople.Thus,theRoadMap’srecommendationsareexpansiveinscope,anddonotsingleoutanyparticularpeopleorgroupsforspecialattention.
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A commitment to eliminating disparities. Racialandethnicdisparitiesinhealthandhealthcarearewelldocumented.TheeliminationofsuchdisparitiesisacriticalcomponentofthenationalpublichealthagendaandakeyprincipleofthisRoadMapaswell.40ThenumbersandproportionofolderadultsfromdiverseracialandethnicoriginsintheUnitedStatesareincreasing.In2003,nonwhiteethnicandracialgroupsrepresented17%ofthepopulationage65andolder,withthatproportionprojectedtoincreaseto28%by2030and39%by2050.41Weembracethisdiversityandrecognizeitsvalueinshapingpolicyinitiatives,communicationstrategiesandlifestyleinterventions,andpopulation-basedsurveillancerelatedtocognitivehealth.
What do we hope to accomplish?
Weenvisionanationinwhichthepublicembracescognitivehealthasapriorityandinvestsinrelatedhealthpromotionandresearch.Toachievethisvision,wehaveadoptedalong-termgoalandavarietyofoutcomesasmoreimmediategoals.
Our long-term goal is to maintain or improve the cognitive performance of all adults.
Fourteenintermediateoutcomesencompasstheareasofcommunication,surveillance,research,policyandpublichealthcapacity.Theseareto:
• Increaseawarenessabouttheimportanceofpromotingandprotectingcognitionamongthegeneralpublic,publichealthandagingprofessionals,andpolicymakers.
• Increaseknowledgeabouttheriskandprotectivefactorsassociatedwithcognitionamongthegeneralpublicandpublichealthandagingprofessionals.
• Decreasemisconceptionsandmythsaboutcognitivehealthamongthegeneralpublic.
• Determinecriticalpublichealthmeasuresformonitoringcognitivefunctionatthepopulationlevel.
• Incorporateappropriatecognitivemeasuresintopublichealthsurveillancesystems.
• Identifytheresearchgapsonmodifiableriskfactorsandcognition.
• Securesustainedsupportforpublichealthresearchtopromoteandprotectcognitivehealth.
StrategicFramework
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“Ifwemaintaincognitivefunctionovertime,thenwearemorelikelytobefunctionallyindependent.”MarilynAlbert,PhDJohns Hopkins Medical Institutions
• Disseminatetheresultsofcriticalpublichealthresearchfindingsaboutcognitivehealth.
• Identifykeypublicandprivatepoliciestoaddresscognitivehealth.
• Modifykeypublicandprivatepoliciestoaddresscognitivehealth.
• Identifysuccessfulpublichealthbestpracticesonvascularhealthanddiabetes.
• Increasecognitivehealthinterventionsthatarecomplementarytovascularhealthanddiabetespublichealthstrategies.
• Securesustainedsupportforpublichealthstrategiestopromoteandprotectcognitivehealth.
• Enhancethecapacityofagingandpublichealthservicenetworkstoimplementeffectiveinterventionstopromoteandprotectcognitivehealth.
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Development ProcessPhase I — Workgroup deliberations
Fourworkgroupsofinvitedexpertsworkeddiligentlyandcollaborativelyovera7-monthperiodtoidentifyrecommen-dationsinfourareasofpublichealthaction:PreventionResearch,Surveillance,PolicyandCommunication.Thechargetoeachworkgroupwastodefineitsareaoffocus,identifyimportantprinciples,andrecommendactionsfor
movingthenationforwardoverthenext3-5yearstowardthelong-termgoalofmaintainingandimprovingthecognitivefunctionofadults.Thedefinitionsandprinciplesthatemergedarepresentedbelow.
Prevention Research Research in public health prevention isdefinedhereasresearchthatappliesandtestspopulation-basedinterventionsthathave
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thepotentialtomaintaincognitivehealth.Recommenda-tionsforcognitivehealthfocusprimarilyontwoareas—vascularriskfactorsandphysicalactivity—withemphasisontheneedforpracticalclinicaltrialstoshowthebenefitsofvascularhealthinterventionsandphysicalactivityonmaintenanceoflong-termcognitivehealth.Theseareaswerechosenbecausetheyarethefirsttoemergefrompopulation-basedstudiesandanimalresearchaspromisingareasforintervention.Whiletheepidemiologicevidencesupportingthebenefitsofvascularhealthforcognitivefunctionismoredefinitivethanthelinkregardingphysicalactivity,bothareasareworthyofattention.Inaddition,recentfindingsfromclinicaltrialshaveheightenedinterestinthevalueofmentalactivitiesbyshowingapositiveeffectfromcognitivetrainingoncertaincognitivedomains.
Researchonpreventionshouldnotbelimitedtotheseareas,however.Otherareas(suchasnutritionandsocialengagement)shouldalsoberecognizedasimportanttoaddressinthefuture.Totheextentpossible,researchshouldbemultidisciplinaryandbuildonafirmunderstandingofhowthepublic,healthcareprofessionals,andavarietyofotherpartnersdefine,perceive,andvaluecognitivehealth.Inaddition,researchmethodologiesshouldconsiderhowtoconvertresultsfrom
randomizedcontroltrialstocommunitysettings;howtomakeclinicalorevidence-basedworkpractical;andhowtotranslateresearchintopublichealthpractice.
SurveillanceSurveillanceisdefinedas“theongoing,systematiccollection,analysis,interpretation,anddisseminationofhealth-relateddata.”42,43,44Theongoingnatureofpublichealthsurveillance,itsapplicationtobroadpopulations,andlimitationsinresourcesoftenrestrictthenatureanddepthofinformationthatcanbegatheredthroughtraditionalsurveillancemethodsusedinresearch.Thesemethodsrangefromcreatingnewsurveillancesystemstousingorenhancingexistingsystems—andsurveillanceofcognitivefunctionisnoexception.Selectingappropriatesurveillancemethodsforcognitivedeclinepresentssomeuniquechallenges,however,suchasdefiningcriteriaforacognitivemoduleandmeasuringavarietyofdimensions(e.g.,riskfactors,attitudes,andburdenofcaregivers).Inaddition,becausemeasurementsmayvaryaccordingtoeducation,language,culture,andraceorethnicity,specialcaremustbetakentoensurethatdataarenotmisinterpretedormisused.
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Methodsavailableforthesurveillanceofcognitivedeclineinolderpopulationsthatdonotrelyonself-reportingfaceparticularconstraints.
Cognitivedeclineinindividualpeopleisdirectlyidentifiedthroughrepeatedmeasurementsconductedoveraperiodoftime.Toimplementthismethodofcaseascertainmentinasurveillancesystemrequireslong-termfollow-upofpopulation-basedcohortswithopen(continuousorsuccessive)enrollments.Suchsystemsarenotoftenusedforchronicdiseasesurveillance,astheyareexpensiveandrequireanextensivetimecommitmentfromparticipants.
Repeatedcross-sectionalpopulationsurveysaremorecommonlyemployedinsurveillance,particularlyforsomechronicdiseasesandforsomeriskfactorsfordisease.Unfortunately,therearenocurrentlyestablishedmethodsthatdefinitivelyascertaincasesofcognitivedeclinethroughcross-sectionalinterviewsalone.Self-reporteddataareinaccurateinthisarea,andtheusefulness,availability,andvalidityofproxy-reporteddataareuncertain.Despitetheselimitations,suchsurveyshavevalueinmeasuringtheprevalenceofriskfactorsforcognitivedecline.Theymayalsohavepotentialtomeasuresomeparametersofcognitive
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functions.Itispossiblethatchangesovertimeinthepopulationdistributionofsuchparametersmaysuggestchangesintheprevalenceofcognitivedecline,althoughsuchinferencescanonlybemadewithcautionevenaftercontrollingforconfounderssuchaseducation,culture,andsocioeconomicstatus.
Othermethodsofscreeningoridentifyingconditionsassociatedwithcognitivedecline(e.g.,geneticscreening,biomarkers,andneuroimagingtests)donotyetappearpractical,althoughsomemayeventuallyproveusefulifthecostsarereasonable.
Recommendationsforsurveillancemustbeofferedwiththesemethodologicalconstraintsinmind,recognizingthetensionbetweenidealmethods,forwhichresourcesmaybedifficulttoobtain,andmorelimitedmethods,forwhichresourcesaremorelikelyavailable.
Policy RealizationoftheRoadMap’svisionrequiresapolicybaseinboththepublicandprivatesectorsthatsupportsandpromotescognitivehealth.Thepublic sectorencompassespolicymakersatfederal,stateandlocallevels.Theprivate sectorincludesbothnot-for-profitandcommercialorganization
policies,suchascoverageofpreventionbyinsurers,humanresourcedepartmentpolicies,employeeassistanceprograms,andotherworkplacepoliciesandpractices.Policychangesinthepublicsectorcaninfluencepoliciesandbehaviorsintheprivatesector;conversely,privatesectorpolicychangecaninfluencepublicpolicy.
Toeffectpolicychange,thepublichealthcaseforaddressingcognitivehealth—thefactthatobservationalevidenceandlimitedshort-termclinicaltrialsnowexisttosupportsomepreventionopportunitiesinthisarea—mustbemadeinaneasilyunderstandableandconsistentmanner.National,stateandlocalorganizations,agenciesandpolicymakersmustbeeducatedaboutcognitivehealthandsubsequentlyengagedtohelppromotepositivepolicydevelopmentandchangethatwillincreaseknowledgeandleadtobettercognitivehealth.
Moreover,policyrelatedtomaintainingcognitivehealthdoesnotjustaddresscare,behaviors,orriskfactorsbutalsopromotesresourcesforbuildingandmaintainingcommunityinfrastructurethatreinforcesindividualbehavior.Thiscouldincludebikeorwalkingtrailstoencouragephysicalactivity,community-wideorganizationsandstructuresthatsupporthealthybehavior,andotherchangestothebuiltandcultural
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environmentsthatadvancethepublichealthgoalofcognitivehealth.Policyinitiativesmustbuildupon,relateto,andbecompatiblewithcommunicationsandresearcheffortsastheytakeshapeandyieldnewinformation.
Communication Thetermcommunication strategyimpliesamultidisciplinaryhealthmarketingapproachthatincludescommunicatinganddisseminatingscientificallyvalidinformationandstrategicinterventionsthroughcustomer-centeredandculturallyappropriatemeans.Acommunicationsstrategyforcognitivehealthaimstoeducate,motivate,andeffectpositivebehaviorchangerelatedtocognitivehealthintargetedandat-riskaudienceswithin3years.
Toeffectivelyreachthisgoal,communicationmessagesandmethodsshould:
• Besciencebased.
• Begearedtopopulationsexperiencingthegreatestdisparitiesandrisksincognitivehealth.
• Reachtheintendedaudienceandpromoteaction.
• Assisttheconsumerinmakingmoreinformeddecisions.
Theaudienceofadultsaged42-60years,alsoknownasbabyboomers,belongstothebiggestgenerationinAmericanhistory.Cognitivehealthissuesprofoundlyaffecttheirparentsnow,andtheywilltouchtheboomersinhugenumbersastheygrowolder.Itisimportanttogetappropriatevalid,evidence-basedmessagestothem,sotheymaytakeactionforthemselvesaswellaspotentiallyinfluencetheirfamilies.Specialfocusshouldbegiventohighriskpopulations,vulnerablepopulationsandhealthcareproviders.Specificracialorethnicgroups(e.g.,AfricanAmericans,Latinos)mayneedtohavetargetedandculturallyappropriatematerialsandtoolsdevelopedbecausetheymaybeatgreaterriskfor
“Developingaroadmapforcognitivehealthprovidesuswithanopportunitytoreducehealthdisparities.Somepopulationsareathighriskforcognitiveimpairmentduetohighratesofhypertensionordiabetes.TheRoadMapgivesusachancetoprovidebetterhealthinformationforallAmericans,includingthoseathighestrisk,sothatpeoplemayimprovetheirmotivationtochangetheirlifestyleforbetterhealthoutcomes.”DebraCherry,PhDAlzheimer’s Association
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experiencingcognitivedeclineduetohigherrisksofvasculardisease,hypertensionanddiabetes.Healthcareprovidersmayhaveneedsandgapsinknowledgethatdifferfromthegeneralpublicbecausetheyareprovidinginformationaboutcognitivehealthtoothers.Aninitialfocusonthesegroupswouldnarrowthescopeofeffort,affordingmoreachievableoutcomes.
Inaddition,beforereachingouttoconsumers,accurateinformationandoptionsshouldbeinplacethroughoutthebroadermedicalandsocialserviceenvironment.Healthcareprofessionalsarethemainsourceofinformationformanyconsumers,andpastexperiencehasproventhebenefitsoftargetingprofessionalorganizationsfirstaspeerinfluencersandtrainersofthesefrontlineproviders.
Phase 2 — Concept-mapping process
Theworkgroupscollectivelyproposed42recommendations:18inpreventionresearch,8incommunications,9inpolicy,and7insurveillance.Aconcept-mappingprocesswasthenusedtoorganizeandvisuallyrepresentthem.Concept-mappingcombinesqualitativeandquantitativemethodstogeneratemapsthatprovideavisualrepresentationofthecomplexrelationshipsamongideasandresults.45Itcanelicitideasfrom
large,diverse,andgeographicallydispersedgroupsaboutaparticulartopicwithinashorttimeframe.Unlikeotherqualitativemethods,conceptmappingalsoprovidesastructuredapproachthatallowskeydecisionmakerstoparticipateinthefinalinterpretationofalargergroup’sperceptions.
Forthisproject,concept-mappingwasorganizedintothreesteps.
Step 1involvedreviewingandrestructuringrecommendationsfromtheworkgroupstoensurethateachrecommendationrepresentedadistinctidea,andidentifyingthelistofstakeholderswhowouldbeinvitedtoparticipate.Thislistincludedmorethan150personsfromabroadarrayofinstitutions,includingstateandfederalagencies,universities,andfoundations.
Step 2consistedofonlineratingandsortingbyinvitedparticipantsandsubsequentanalysesoftheresults.46Fortheratingprocess,140(ofthe150)participantswereaskedtorateboththerelativeimportanceofeachrecommendationanditscurrentactionpotential.Forthesortingtask,20ofthese140participantswerealsoaskedtocategorizetherecommendationsaccordingtotheirviewofsimilarmeaningsorthemes.Ten(ofthe150)participantswereinvitedto
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participateinthesortingtaskonly.Becausetheratingandsortingprocesswasanonymous,exactfiguresonparticipationarenotavailable;however,basedonthenumberoftotalresponses,69persons(outof140,or49.3%)providedinputintoratingtheimportanceandactionpotentialofeachrecommendation.Additionally,23persons(outof30,or76.7%)organizedtherecommendationsintocategoriestoidentifythemesorpatterns.Multivariatestatisticaltechniqueswereusedtoorganizeandvisuallypresentresultsoftheonlineprocessinaseriesofconceptmapsthatreflectedrelationshipsbetweenrecommendationsandtheclusteringofrecommendationsintocategories.
Step 3 encompassedthereviewandinterpretationoftheresultsofPhase2,andselectionofpriorityrecommenda-tions.MembersoftheSteeringCommitteereviewedthemapstoensurethattherecommendationsineachoftheeightclusterswereconsistentwiththeoverallthemeofthatcluster.
TheCommitteereconstructedafewrecommendationscreatingtwoadditionalrecommendations(foratotalof44recommendations)andintwoinstancesmovedrecom-mendationstoadifferentcluster.Thefinalclusterlabelsare:
• Disseminatinginformation• Translatingknowledge• Conductingsurveillance• Implementingpolicy• Measuringcognitiveimpairmentandburden• Movingresearchintopractice• Conductinginterventionresearch• Developingcapacity
Asafinalstep,theSteeringCommitteechoseasetofpriorityrecommendationsoractions.
“Iamveryimpressedwiththeprocessbecausethisisafieldinwhichpeoplehavestrongopinionsonmanydifferentissues.Whatimpressedmewasthattheparticipantsinthereviewprocesswereopentohearingabroadrangeofopinionsbutintheendoptedforscientificrigorastheguidingfeatureonwhichrecommendationswerebased.”PeterRabins,MD,MPHCoauthor, The 36 Hour Day
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Actions by ClusterTheRoadMapisa“living”documentexpectedtoevolveovertime.Someactionsareachievablewithin1to3years,whileotherswillrequiremoretimetocometofruition.Somearelinkedandneedtooccurinacertainsequence,withtheoutcomesofthefirstsettingthestageforinitiatingthenext.And,whilenoparticularagegroupissingledoutforspecialattention,theRoadMapconcentratesprimarilyon
interventionsformiddle-agedandolderadults.Thisfocusrecognizesthatinterventionstoreducerisksarebestbegunearlyinlife;yet,adults,particularlyolderadults,aremorelikelytobeconcernedandmotivatedtotakeaction.
ThefullsetofRoadMapactionsfallintoeightclusters.Withineachcluster,theactionsarelistedinnospecialorderofpriority.Theletterinparenthesesaftereachactionrefers
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tothegroup(eitherworkgrouporSteeringCommittee)thatoriginallyproposedit(P=PreventionResearch,C=Communication,P=Policy,S=Surveillance,SC=SteeringCommittee).Alloftheactionsgeneratedbythegroupsareincluded.
Inofferingtheseactions,wecannotunderestimatethecomplexitiesoftranslatingthemintoaction.MostessentialisacommitmenttobasethisRoadMaponscientificevidence,movingforwardcollaborativelytoleverageexistingresourcesandactivitiesaspromotionactivitiesbecomedefined.Keypartnershipsmustbeformedamongadiversearrayoforganizationsandagenciestobuildoncollectivestrengths,delivercompatiblemessagesandinterventions,andassureefficientuseofresources.Existinghealthpromotioncommunitiesassociatedwithheartdisease,stroke,diabetes,andphysicalactivityareinvaluableresourcesforpromotingcognitivehealth.
Disseminating information
1. Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions. (SC)EvidenceexiststhatthecurrentboomergenerationisconcernedaboutcognitivehealthandfearsAlzheimer’sdisease.Onecriticalareaoffocusshouldbeonhelpingthepublictounderstandthevaryinglevelsofevidencebehindproposedinterventionsregardingcognitivehealth.Unlesscredibleandbroadreachinginformationaboutvalidinterventionsincognitivehealthisdisseminated,consumerswillfillthegapwithuntestedprogramsandproducts.Notonlycantheseprogramsandproductspresentaneconomicburden,butsomemayalsodistracttheagingpopulationfrommeaningfullifestylechanges.Communicationsstrategies(includingtheappropriatecommunicationchannels)shouldbuilduponcurrenteffortsbyvariousorganizationsandagenciestoshareexistinginformationandmaterialsoncognitivehealthresearchandpossibleinterventionsthatareconsistentwithcurrentscience.
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2. Develop communications strategies and tools
to increase awareness among health care providers,
public health professionals, and aging service
providers at the national, state, and local levels about
the current state of science of cognitive health. (C)Indisseminatinginformationtothepublic,informationmustbefilteredthroughtrustedhealthandcommunityresources.Providingprofessionalswithaccurate,evidence-basedinformationandtoolswillrespondtothegrowinginterestamongconsumersregardingquestionsonpreservingcognitivehealth.
3. Develop and implement a training curricula
related to cognitive health for continuing
professional education of health and human
services professionals. (P)Toincreasetheawarenessandknowledgeofprofessionalsinhealthandhumanservices,strategiesshouldbedevelopedinbothpreserviceandin-servicemodalities.Bringingnewprofessionalsintothefieldwithappropriateknowledgeisnotenough;thelevelofunderstandingofpracticingprofessionalsmustalsoberaisedsothattheycanhelpthepublicsortoutevidence-basedapproachestocognitivehealthfromlessprovenorundemonstratedoutcomes.
4. Develop creative and replicable means for raising
the public’s awareness of cognitive health and
engaging the public in promoting the importance
of cognitive health through policy. (P)Thepublicplaysanimportantroleinstimulatingbothpublicsectorandmarketplaceactiononissuesitfindsimportant.Itisessentialthatthepublicbeeducatedbasedoncurrentscienceandknowledgeofbestpractices.Thiswillcontributetothedevelopmentofanewconventionalwisdomregardingcognitivehealth.
5. 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-shop,go-toplaceforvalidandtestedinformationwillprovideconsumersandprofessionalswhoserveolderadultsandtheirfamilieswiththetoolstomakeinformeddecisionsabouttheirhealthandeffectpositivebehaviorchange.Thesitewouldprovideguidingprinciplestohelpconsumersandhealthinformationprovidersandprofessionalstoevaluatelocalservicesthataddresstheseconcernsandtomaintaincurrent
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understandingaboutcognitivehealthandtheseinterventionsasthesciencebecomesmoresophisticated.
Translating knowledge
1. Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors. (R)Itisnotclearhowthegeneralpublicorpractitionersperceiveandunderstandcognitivehealth.Todevelopusefulprograms,itwillbeimperativetobetterunderstandthediversetargetaudiences.Someissuesthatwouldbeimportanttounderstandfortranslationtoboththegeneralpublicandpractitionersinclude:howcognitionisdefinedandtranslated;whataspectsofcognitivehealthareimportant(includingthelevelofknowledgeaboutvascularfactors);andhowconcernedthegeneralpublicisaboutcognitivehealth.
2. Help people understand the connection between risk
and protective factors and cognitive health.(C,SC)Riskandprotectivefactorsarekeystofiguringouthowtoaddressindividualandcommunityhealthandrequire
clarifyingforthepublicwhatisdemonstratedaseffectiveinclinicaltrialsversusassociationsobservedinotherstudies.Ofprimaryinterestareaspectsofpersonalandenvironmentalexperiencesthatmakeitmorelikely(riskfactors)orlesslikely(protectivefactors)thatpeoplewillexperiencecognitivedecline.Considerationshouldbegiventotheseconnectionsandtopromotingabetterunderstandingofit,includinganunderstandingofareasinwhichclinicaltrialshave(orhavenotyet)establishedacauseandeffectbetweenriskandprotectivefactorsandcognitivehealth.
3. Develop a mechanism to review cognitive health
messages and programs to determine their
scientific accuracy and public credibility. (C)Currently,thepublichasnosinglesourceofinformedandvalidrecommendationsforprograms,services,andlifestylerelatedinterventionstoaddresspositivemeasuresincognitivehealth.Creatingasystemforreviewingthegrowingnumberofprogramsandprovidingpublicaccesstothereviewsgeneratedwillmoveconsumersclosertoinformeddecisionsandmorepositiveinvestmentsinhealth.
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Implementing policy
1. Initiate policy changes at the federal, state, and local
levels to promote cognitive health by engaging
public officials.(P)Far-reachingpublichealthissuesdemandinformedactionbypublicofficials,becauseactionbytheprivatesectoralonewillbeinsufficienttoreachdesiredresults.Becauseprogramandfundingdecisionsaremadebypolicymakersatthenational,stateandlocallevels,itisimportanttoengageandeducatethisaudience.Publicofficialshavesignificantcompetinginterests;itisessentialthattheybecomeeducatedandengagedinthisarenatocontributetopositivepolicychangeincognitivehealthinterventionsandtosupporttheneedforfurtherresearch.
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 2020willrepresentasystematicandwidelyrecognizedapproachtoimprovinghealth.Asresearchdemonstrateswaysinwhichcognitivehealthcanbe
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maintained,theareaofcognitivehealthcanbeelevatedtoamajorhealthprioritybybeingincorporatedintotheoutcome-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)IncludingcognitivehealthinsuchdocumentsastheState of Aging and Health in America Reportwouldelevateitsstatusasarecognizedpublichealthissueandmakedatareadilyavailableforaction.Armedwithimportantdatafromthisandothermonitoringsystems,publichealthprofessionalswillbepreparedtomovepolicyforwardtotestinterventions.
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.
Theyshouldbebaseduponsuchcriteriaastheabilityto:examineevidence-basedresearch;establishon-goingformsofdialogue;buildleadershipandcapacityrelatedtopolicyandpublicandprofessionaleducation;addressdiverseculturalandethnicpopulations;providefunding;andexplorethelinksbetweenthevascularfactors,physicalactivity,andcognitivehealth.
5. Engage national organizations and agencies that
focus on the older population, and educate these
agencies about cognitive health and its connection
to their missions.(P)Toachievebroad,effectivecollaborationsforcognitivehealthandemotionalwell-being,nationalorganizationsandagenciesmustidentifyandagreetocommonground.Nationalorganizationsandagenciesareessentialtobothreachinglargenumbersofindividualmenandwomenandtousingtheirinfluencetoeducatepolicymakersandopinionleaders.Educationofthepublicandleadersofkeyorganizationsisaprecursortopolicychangerelatedtocognitivehealth.
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6. Convene policy experts to identify and examine
current policies (e.g., national policy, state
policy, private sector policy) that could be
modified, modernized, or broadened to include
cognitive health.(P)Policiesshouldbeamendedtoreflectcurrentscienceandknowledgeandbeinclusiveofcognitivehealth.Adjustingandamplifyingcurrentpoliciesareefficientandeconomicalroutestosystemschange.
7. Promote the modification of existing national
and state public health plans to include cognitive
health in their strategies or recommendations
where appropriate.(P)Nationalandstatepublichealthplanssignificantlyinfluenceeffortsinpublichealthandserveasabarometerofimprovement.Asinterventionsaredemonstratedthatcanhaveaneffectoncognitivehealth,includingitintheseplanswouldelevateitsstatusasarecognizedpublichealthissueandprovideavenuefortheevaluationofprogress.
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) Clearlydefinedgoalsofpublichealthsurveillancewillpromotethedevelopmentofappropriatesurveillancesystemsandthecollectionofconsistentdatathatprovideusefulinformationtoinformpublichealthpolicy.Goalsofthesurveillancesystemmayinclude:definingtheburdenofcognitivedeclineinthepopulation;monitoringthetrendsinburden(e.g.,prevalence,incidence);monitoringtrendsinriskfactors;definingthepopulationatincreasedrisk;anddeterminingwhetheradditionalanalysesshouldbeperformedforthepurposeofpublichealthsurveillance.
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(e.g.,BehavioralRiskFactorSurveillanceSystem,HealthandRetirementStudy,NationalHealthInterviewSurvey)to
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addressissuesrelatedtocognitivedeclineislesscostlyandmaybemoreefficientthandevelopingnewsurveillancesystems.However,thereareimportantlimitationsofexistingsystemsandthedatatheycollect;inparticular,mostarecrosssectionalratherthanlongitudinal.Manyarealreadyquitelengthy,withmajorconstraintsonaddingnewitems.Closeexaminationofthesesystemswillensurethattheyareamendedappropriatelyandcost-effectively.
3. Identify existing studies that measure longitudinal
trends in cognitive function.(S)Existinglargecohortorotherlongitudinalstudiesofcognitivedeclinemayprovideitemsthatcouldbeincorporatedintosurveillancesystemsformeasuringsuchdecline.Someofthesestudiesmayhavevalidateditemsusedpreviouslyinbothmajorityandminoritypopulationsthatestimatevariabilityandtruechangeovertime.
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-basedsurveillancesystemwouldassistinthecollectionofconsistentdatatomonitor,assess,and
informpublichealthprogramsandpolicyaboutthepublichealthburdenofcognitiveimpairment.
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) Itiscriticaltoexamineallstudiestodatetodocumentwhichinterventionshavebeenproveneffective.Suchreviewsshouldfocusondeterminingtherelationshipsbetweenriskfactors,protectivefactors,andcognitivefunctionacrossobservationalandclinicaltrials.Whereinterventionsexist,theireffectivenessshouldbedocumentedandremaininggapsinthefieldshouldbeidentifiedinordertomovestrategiesintopublichealthpractice.
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.(R,SC)
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Itiscriticaltoexamineallstudiestodatetodocumentwhichinterventionshavebeenproveneffective.Suchreviewsshouldfocusondeterminingtherelationshipsbetweenriskfactors,protectivefactors,andcognitivefunctionacrossobservationalandclinicaltrials.Whereinterventionsexist,theireffectivenessshouldbedocumentedandremaininggapsinthefieldshouldbeidentifiedinordertomovestrategiesintopublichealthpractice.
3. Conduct a systematic literature review on the
relationship between treatment of diabetes and
cognitive health. (R)Someevidencesuggeststhatdiabetesisariskfactorforcognitivedecline.Recommendationsfortypesofdiabetesmanagement(e.g.,medications,lifestylemodification)thatmightalsobebeneficialforcognitivehealthcannotbemadewithoutareviewoftheliteraturerelatingdiabetesinterventionstocognitivechange(andmostlikelyundertakingadditionalclinicaltrials),andidentificationofareasthatneedtobeclarifiedbeforespecificinterventionscanbeproposed.
4. Conduct a systematic literature review on the
relationship between treatment of hypertension
and cognitive health.(R)Hypertensionisaknownriskfactorforstroke,andthereforeforvasculardementiaandcognitivedecline.Recommendationsfortypesofantihypertensivetherapyandtherangesofbloodpressurefordifferentagegroupsrecommendedformaintainingcognitivehealthcannotbemadewithoutareviewoftheliteraturerelatinghypertensiveinterventionstocognitivechange,andprobablynotwithoutpursuingadditionalclinicaltrials.Thesystematicliteraturereviewwouldidentifyareasthatneedtobeclarifiedbeforespecificinterventionscanberecommended.
5. Identify gaps in knowledge about cognitive health
and related lifestyle changes, and determine
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whether these vary by specific groups. (C) Todevelopappropriatematerialsandtools,thegapsin
knowledgeneedtobeunderstood,especiallyamonghigh-riskpopulations,vulnerablepopulations,andhealthcareproviders. Specificracialorethnicgroupsmayneedtohavetargetedandculturallyappropriatematerialsandtoolsdevelopedbecausetheyareatgreaterriskforexperiencingcognitivedecline.Healthcareprovidersmayhaveneedsandgapsinknowledgethatdifferfromthegeneralpublicbecausetheyarealsoprovidinginformationtoothersaboutcognitivehealth.
6. Conduct a systematic review of lifestyle interventions
and contextual factors to examine the benefits and
barriers to their adoption and maintenance. (R)Understandingthebenefitsofandbarrierstoadoptingandmaintaininganinterventionisoneofthecriticalstepsfortranslatinginterventionseffectivelyandefficaciouslyinacommunity-basedsetting.
7. Conduct reviews of the literature to determine
the prescriptions for physical activity (e.g., type,
frequency, duration, and intensity of activity) that
are effective in enhancing cognitive function.(R)Itisimportanttoknowwhatkindsofphysicalactivitystimuliarenecessarytopromotecognitivehealth.Anexaminationofthescientificliteraturewillidentifygapsinknowledgeandfocusresearch.Withoutsuchinformationandresearchdevelopment,accurateadvicecannotbeconveyedtothepubliconhowactivetheyshouldbetomaintaintheircognitivehealth.
8. Develop cognitive health interventions that
reflect the most current scientific research and
that are consistent with effective community-
based interventions. (C,SC)Clinicaltrialsassessingtheefficacyofinterventionstoeffectcognitivefunctionandpublichealthstudiesexaminingtheeffectivenessandfeasibilityofcommunity-basedinterventionsareoftenreportedseparately.Morecomprehensiveapproachesinvolvingcollaborationsbetweenclinicalresearchersandcommunityparticipatoryresearchersarecriticaltoensurethattheeffectivenessandfeasibilityofcognitivehealthinterventionsaredevelopedandtestedwithvariouscommunities.
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Conducting intervention research
1. Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function. (R)Todate,fewvascularstudies(includinglarge-scalecontrolledclinicaltrialsofolderadultcohorts)havecombinedcognitivehealthoutcomesandvascularoutcomesinasinglestudy.
2. Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of cog-
nitive decline and improving cognitive function. (R)Todate,few,ifany,physicalactivitystudies(includinglarge-scalecontrolledclinicaltrialsofolderadultcohorts)havecombinedoutcomesforcognitivehealthandphysicalactivityoutcomesinasinglestudy.
3. Conduct physical activity studies to determine the
long-term benefit of physical activity as it relates
to cognitive function. (R)Todate,studiesofphysicalactivityinterventionsthathaveassessedcognitiveoutcomestypicallyhavenofollow-upatalloronlyashortfollow-up.Studiesofphysicalactivity
areneededtodeterminetowhatextentanycognitivebenefitsassociatedwithphysicalactivitypersistacrosslong-termfollow-up:at6month,1year,orlongertimeperiods.Long-termfollow-upstudiesofphysicalactivityarealsoneededtodeterminethedurationofcognitiveeffectsinthosewhostoptheprogram.
4. Conduct studies to determine the physical activity
prescription (e.g., type of activity, frequency,
duration, and intensity) needed to maintain or
promote cognitive functioning. (R)Smallclinicaltrialshaveshownthataerobicactivity(e.g.,walkingseveraltimesaweekfor6monthsduration)wascapableofproducingcognitiveimprovementinolderadults,atleastintheshortterm.Thesefewstudies,however,haveyettoyielda“prescription”thatcouldbegiventoolderadults;thus,manyquestionsremaintobeansweredaboutthetypesofactivity(e.g.,aerobicoranaerobic,individualorgroup)andtheirduration,intensity,andfrequencythatareneededtomaintain,orevengain,goodcognitivefunction.
5. Conduct studies to determine the effect of physical
activity and physical activity relapse on persons of
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different backgrounds in relation to cognition. (R)Similartothepharmacogeneticsapproachthathasbeenusedtodeterminetheefficacyofspecificdrugsforpersonswithcertaingenotypes,itseemspossiblethatrecom-mendationsforbehavioralinterventionssuchasphysicalactivitymightbecraftedtoanindividualperson’sbackground(e.g.,geneticendowment,culturalcontext,lifehistories,fitnesslevels,andage).
6. Identify how physical activity relates to those
aspects of cognitive functioning that are important
to the successful performance of activities of daily
living and instrumental activities of daily living.(R)Itisimportanttounderstandhowanycognitivebenefitmeasuredinthelaboratorytranslatestobetterfunctioninginrealworldtasks.Althoughwell-controlledlaboratorystudiesareessentialtoadvancingknowledgeinthisarea,itiscurrentlynotclearhowmuchthecognitivetasksassessedinthesestudieswillgeneralizetothecognitivefunctioningrequiredinroutinedailyactivitiesimportanttoolderadults,suchasbalancingacheckbook,safelydrivingacar,andcompliancewithprescriptionsformedications(i.e.,knowinghowmanyorwhatpillstotakewhen).
7. Determine the feasibility of conducting secondary
analyses of existing studies to examine the
relationship between physical activity and the
maintenance of cognition. (R)Itisrecognizedthatsecondaryanalysesofexistingdatasetsoftenpossessmethodologicalproblems(includingcrosssectionaldata).Nevertheless,datasets(perhapsevensomerepresentativeoftheU.S.population)mayexistthatcontainvariablesrelatedtocognitivefunctioning,health,andphysicalactivity.Effortstolocatesuchdataandtoevaluateresearchquestionsandassociationsamongthevariablesmayprovideadditionalinsightsintothisarea.
8. Identify the mechanisms that may mediate
the relationship between physical activity and
cognitive functioning.(R)Physicalactivitymaynotaffectcognitivefunctiondirectlybutitmaystillaffectitthroughintermediatemechanisms.Itisimportanttoknowwhethertheassociationbetweenphysicalactivityandcognitivefunctioningismediatedbychangesindiabetesoutcomes,invascularfitnessoutcomes,orinriskfactorssuchashypertensionorhyperlipidemia.
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9. Encourage cardiovascular disease and diabetes
researchers to use appropriate measures addressing
cognitive domains as outcomes in their studies.(R)Thebestwaytounderstandwhichinterventionsincardiovasculardisease anddiabeteswillaffectcognitivehealthisforappropriateaspectsofcognitivemeasurestoberoutinelyincludedinappropriatestudiesinthesetwoareas.
10. Encourage research to determine the impact of
multiple vascular risks on cognition. (R)Specificfocusisneededtobothunderstandthebiologyofhowvascularriskfactorsaffectcognitionandtodeterminewhethertheeffectsofhavingmultiplefactorsareadditiveormultiplicative. Someobservationalstudieshavesuggestedthatthegreaterthenumberofvascular riskfactors,thegreaterthecognitivedeficit.Weknow,however,thatclinicaltrialswithpharmacologicalagentsthatcontrolindividualriskfactorshaveeffectivelyreducedvascularriskbuthavenotconsistentlyproducedcognitivebenefit.Abetterunderstandingofthemechanismsbywhichmultiplevascularriskfactorsmaycontributetocognitivedeficitscouldidentifytargetsforinterventionsto
reverseorreducethedeficit.Thebiologicalmechanismsoftheinteractionamongriskfactors,aswellasmodelsofthesizeoftheinteractioneffectoncognition,wouldassistindesigningtrialsofpotentiallyeffectiveinterventions.
11. Conduct research on other areas potentially
affecting cognitive health such as nutrition, mental
activity, and social engagement. (R)Scienceisevolvingregardingriskandprotectivefactorsintheareasofcognitivetraining,nutrition,andsocialengagement.Itiscriticaltomonitorandincludetheseareasasthescienceemerges.
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Measuring cognitive impairment and burden
1. Identify thresholds for cognitive decline that have
functional importance for population-based
surveillance systems. (S)Itisimportanttorecognizepointsonthecontinuumofcognitivedeclinethatarefunctionallymeaningful.Itshouldalsoberecognizedthatmeasurementsbeyondsomepointsonthiscontinuummayrequireinformationfromproxyrespondents.Usefulcomparisonsoffindingsfromdifferentsurveillancesystemsandresearchstudiesareimprovedifthereisconsistencyamongthethresholdsbeingused.Functionallyimportantthresholdsshouldbeofpracticalsignificancetohelpinformpublichealthpolicyregardingneedsforcaregiversupportandotherspecialhealthcareorsocialservices.
2. Identify critical dimensions of cognition and the
most appropriate corresponding measures that
may be useful in surveillance systems. (S)Itisimportanttoknowthekeycomponentsofcognition(e.g.memory,intelligence,problemsolving,andreasoning)thataremostsensitiveandspecifictocognitivedeclineandpracticallymeasurableinsurveillancesystems.
Useful,measurablecomponentsareexpectedtodifferaccordingtothenatureofthesurveillancesystem,particularlywhetherdatacollectionislongitudinalorcross-sectional.Withcrosssectionaldataalone,fewerinferencesarepossibleregardingage-relatedcognitivedecline.
3. Identify measures of the public health burden
of cognitive impairment on individual people,
families, and communities.(SC)Thepublichealthburdenofcognitiveimpairmentencompassesitseffectsonindividualmenandwomen,caregivers,families,employers,andothersinthecommunity.Theseeffectsmayhavephysical,mental,social,andeconomicdimensions.Itisimportanttoidentifykeymeasurablecomponentsoftheseeffectstoenablethepublichealthburdentobefullyassessed,monitored,anddescribed.
4. Identify a set of questions appropriate for use in
people of diverse educational attainment, culture,
and ethnicity that will measure cognitive function
with sufficient sensitivity, specificity, and
predictive values.(S)
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Thesequestionsmightexistwithinanongoingpopulation-basedsurveillancesystem,ortheycouldbeaddedtosuchasystem.Totheextentpossible,education-andculture-independentmeasuresshouldbesought.Becausetheeffectsofeducationandculturearepotentialconfounders,measuresandanalytictechniquesareneededthatwouldenablereducedcognitivefunctiontobedistinguishedfromlowperformanceduetovariationsineducationalorculturalexposures.Itiscriticaltorecognizeandcorrecttheseconfoundingeffectssoastoavoidmisinterpretingormisusingsurveillancedata.
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)Supportofresearchoncognitivehealthisexpensiveinscope,effort,andcost.Partnershipswithfederalagencies,foundations,andotherentitieswilllikelybenecessarytosecuresuchsupportandconductthisresearch.
2. Convene researchers and community intervention-
ists conducting interventions on risk and protective
factors to identify potential mechanisms to advance
the work in the field of cognitive health.(R)Thefieldsofcardiovasculardisease,depression,diabetes,andcognitionarebeginningtointersect.Afterconductingliteraturereviewsonwhatiscurrentlyknownabouttheeffectsofinterventionstargetingvascular factors,depression,anddiabetesoncognitivehealth,researchersandcommunityinterventionistsineachofthesefieldsshouldbeconvenedtodeterminestrategiesformovingthefieldofcognitivehealthforward.
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Centers for Disease Control and Prevention and the Alzheimer’s Association|��
NextStepsPriorities for action
WhilewebelievethatalloftheactionspresentedinthisRoadMapareimportant,wearemindfulofthelimitedpoolofresourceswithwhichtoimplementthem.Becauseofthisreality,weselected10actionsofhighestpriorityforimmediateattention.
IVdevelopment
process
Vactions by
cluster
VInext steps
IIIstrategic
framework
IIstate of
knowledge
Ibackground
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• Determine how diverse audiences think about
cognitive health and its associations with
lifestyle factors.
Itisnotclearhowthegeneralpublicorpractitionersperceiveandunderstandcognitivehealth.Todevelopusefulprograms,itwillbeimperativetobetterunderstandthediversetargetaudiences.Someissuesthatwouldbeimportanttounderstandfortranslationtoboththegeneralpublicandpractitionersinclude:howcognitionisdefinedandtranslated;whataspectsofcognitivehealthareimportant(includingthelevelofknowledgeaboutvascularfactors);andhowconcernedthegeneralpublicisaboutcognitivehealth.
• Disseminate the latest science to increase public
understanding of cognitive health and to dispel
common misconceptions.
EvidenceexiststhatthecurrentboomergenerationisconcernedaboutcognitivehealthandfearsAlzheimer’sdisease.Onecriticalareaoffocusshouldbeonhelpingthepublictounderstandthevaryinglevelsofevidencebehindproposedinterventionsregardingcognitivehealth.Unlesscredibleandbroadreachinginformationaboutvalid
interventionsincognitivehealthisdisseminated,consumerswillfillthegapwithuntestedprogramsandproducts.Notonlycantheseprogramsandproductspresentaneconomicburden,butsomemayalsodistracttheagingpopulationfrommeaningfullifestylechanges.Communicationsstrategies(includingtheappropriatecommunicationchannels)shouldbuilduponcurrenteffortsbyvariousorganizationsandagenciestoshareexistinginformationandmaterialsoncognitivehealthresearchandpossibleinterventionsthatareconsistentwithcurrentscience.
• Help people understand the connection between
risk and protective factors and cognitive health.
Riskandprotectivefactorsarekeystofiguringouthowtoaddressindividualandcommunityhealthandrequireclarifyingforthepublicwhatisdemonstratedaseffectiveinclinicaltrialsversusassociationsobservedinotherstudies.Ofprimaryinterestareaspectsofpersonalandenvironmentalexperiencesthatmakeitmorelikely(riskfactors)orlesslikely(protectivefactors)thatpeoplewillexperiencecognitivedecline.Considerationshouldbegiventotheseconnectionsandtopromotingabetterunderstandingofit,includinganunderstandingofareasinwhichclinicaltrials
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have(orhavenotyet)establishedacauseandeffectbetweenriskandprotectivefactorsandcognitivehealth.
• 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.
Itiscriticaltoexamineallstudiestodatetodocumentwhichinterventionshavebeenproveneffective.Suchreviewsshouldfocusondeterminingtherelationshipsbetweenriskfactors,protectivefactors,andcognitivefunctionacrossobservationalandclinicaltrials.Whereinterventionsexist,theireffectivenessshouldbedocumentedandremaininggapsinthefieldshouldbeidentifiedinordertomovestrategiesintopublichealthpractice.
• Conduct controlled clinical trials to determine the
effect of reducing vascular risk factors on lowering
the risk of cognitive decline and improving
cognitive function.
Todate,fewvascularstudies(includinglarge-scalecontrolledclinicaltrialsofolderadultcohorts)havecombinedcognitivehealthoutcomesandvascularoutcomesinasinglestudy.
• Conduct controlled clinical trials to determine the
effect of physical activity on reducing the risk of
cognitive decline and improving cognitive function.
Todate,few,ifany,physicalactivitystudies(includinglarge-scalecontrolledclinicaltrialsofolderadultcohorts)havecombinedoutcomesforcognitivehealthandphysicalactivityoutcomesinasinglestudy.
• Conduct research on other areas potentially affecting
cognitive health such as nutrition, mental activity,
and social engagement.
Scienceisevolvingregardingriskandprotectivefactorsintheareasofcognitivetraining,nutrition,andsocialengagement.Itiscriticaltomonitorandincludetheseareasasthescienceemerges.
• 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-basedsurveillancesystemwouldassistinthecollectionofconsistentdatatomonitor,assess,andinform
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publichealthprogramsandpolicyaboutthepublichealthburdenofcognitiveimpairment.
• Initiate policy changes at the federal, state, and local
levels to promote cognitive health by engaging
public officials.
Far-reachingpublichealthissuesdemandinformedactionbypublicofficials,becauseactionbytheprivatesectoralonewillbeinsufficienttoreachdesiredresults.Becauseprogramandfundingdecisionsaremadebypolicymakersatthenational,state,andlocallevels,itisimportanttoengageandeducatethisaudience.Publicofficialshavesignificantcompetinginterests;itisessentialthattheybecomeeducatedandengagedinthisarenatocontributetopositivepolicychangeincognitivehealthinterventionsandtosupporttheneedforfurtherresearch.
• 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 2020willrepresentasystematicandwidelyrecognizedapproachtoimprovinghealth.Asresearchdemonstrateswaysinwhichcognitivehealthcanbemaintained,theareaofcognitivehealthcanbeelevatedtoamajorhealthprioritybybeingincorporatedintotheoutcome-orientedapproachusedbyHealthy People 2020.
Theseprioritiescutacrosstheclustersand,asapackage,wouldputour“bestfootforward”inmeetingthepublichealthchallengesofcognitivehealth.Thepriorityactionsputforthrepresentthebestthinkingofleadingexpertsacrossdiversefieldsofinfluence.Theyhavebeenidentifiedasonesthatarenecessarytomovingtheissueofcognitivehealthintopublichealthpractice.Weurgethenationtoadoptthese10actionsandtojoinforcesinimplementingthemoverthenext3-5years.Doingsowouldbemakingtremendousstridestowardsachievingourlong-termvision:maintainingorimprovingthecognitiveperformanceofalladults.
NextSteps
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Implementation
EffectiveimplementationoftheactionsoutlinedinthisRoadMaphingesonseveralfactors.
• Organizationswillneedtoidentifyclearlywhichactionstheywishtoaddress,andcollaboratewithothergroupsthatshareaninterestinthoseactions.
• Organizationsshoulddevelopandstrengthenpartnershipswithotherlike-mindedorganizations.
• Organizationsshoulddeveloptheirownplanstoachievetheirselectedactions.
• Organizationsshouldestablishsystemstotracktheirprogresstowardscompletingtheirplansofactionandtofacilitatecommunicationandexchangeofinformation.
Asthescienceofcognitivehealthiscontinuallyevolving,theRoadMapshouldbeviewedasalivingdocumentthatcontainsawiderangeofactionsonhowtoproceed.Asweachievesomeoftheactions,wecanusetheRoadMaptomoveforwardandaddressotheractionsthatbecomerelevantandfeasible.
Conclusion
ThisRoadMapcomesatacriticaltimewhenscientificinterestincognitivehealthisbeginningtomeettheburgeoningdemandofthepublicforwaystomaintaincognitivefunction.Itsetsinmotionacourseofactionforestablishingpartnerships,makingcognitivehealthaprominentpublichealthissue,andpreparingsocietyforconcertedeffortstomaintainingthecognitivehealthofolderAmericans.
TheRoadMapisbothacalltoactionandaguideforimple-mentinganeffectivecoordinatedapproachtomovingcognitivehealthintopublichealthpractice.Thekeytosuccessliesincontinuingandexpandingresearch,developingandchannelingresources,andworkingcollaborativelytomovetheevidenceaboutmaintainingcognitivehealthintonationalaction.
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Communications WorkgroupMaryGuerriero Austrom,PhDIndiana Alzheimer’s Research Center Indiana University School of Medicine
FrankBailey,JDAARP
DianeBazelidesAlzheimer’s Association National Board
VickyCahanNational Institutes of Health
NancyCeridwynAmerican Society on Aging
MarthaDiSarioPacific Communications Enterprises
BarbaraE.Gill,MBAThe Dana Foundation The Dana Alliance for Brain Initiatives
JeffMcKennaCenters for Disease Control and Prevention
MichaelC.PattersonAARP
DeloresPluto,PhDUniversity of South Carolina
MarySchwartz,MSAlzheimer’s Association
BobRosenblattNational Academy of Social Insurance
Policy WorkgroupWilliamF.BensonHealth Benefits ABC’s
JoyCameronNational Governors Association
IrisFreemanAdvocacy Strategy
KathrynGallagherCenters for Disease Control and Prevention
RobynGolden,LCSWRush University Medical Center
CatherineGordon,RN,MBACenters for Disease Control and Prevention
MaryGuthrieAdministration on Aging
DavidHoffman,MEdNew York State Department of Health
JimHowardCalifornia Department of Health Services
DebraLappin,JDB&D Consulting LLC
StephenMcConnell,PhDAlzheimer’s Association
SandyMarkwoodNational Association for Area Agencies on Aging
MarkSchoeberlAmerican Heart Association
PaulTibbitsJr.American Diabetes Association
Prevention Research WorkgroupMarilynAlbert,PhDJohns Hopkins Medical Institutions
MargaretGatz,PhDUniversity of Southern California
J.NeilHenderson,PhD University of Oklahoma Health Sciences Center
KathrynJedrziewski,PhDInstitute on Aging University of Pennsylvania
RhondaMontgomery,PhDUniversity of Wisconsin - Milwaukee
MarcelleMorrison-Bogorad,PhDNational Institute on Aging
PeterRabins,MD,MPHJohns Hopkins University School of Medicine
MarySano,PhDAlzheimer’s Disease Research Center Mount Sinai School of Medicine
JesusSoares,MSc,ScDEmory University Centers for Disease Control and Prevention
WilliamThies,PhDAlzheimer’s Association
BarbaraVickrey,MD,MPHUniversity of California at Los Angeles
MollyWagster,PhDNational Institute on Aging
NancyWhitelaw,PhDNational Council On Aging
ShereeMarshallWilliams,PhD,MScCenters for Disease Control and Prevention
KristineYaffe,MDUniversity of California, San Francisco San Francisco Veteran’s Administration Medical Center
Surveillance WorkgroupDallasAnderson,PhDNational Institute of Aging
HughC.Hendrie,MB,ChB,DScIndiana University Center for Aging Research Regenstrief Institute, Inc.
Walter“Bud”Kukull,PhDUniversity of Washington
JamesN.Laditka,DA,PhD,MPAUniversity of South Carolina
KennethM.Langa,MD,PhDUniversity of Michigan
EricB.Larson,MD,MPHGroup Health Center for Health Studies
LenoreLauner,PhDNational Institute on Aging
LisaC.McGuire,PhDCenters for Disease Control and Prevention
DanMungas,PhDUniversity of California, Davis
NathaliedeRekeneire,MD,MSCenters for Disease Control and Prevention
PaulScherr,PhD,DScCenters for Disease Control and Prevention
DavidThurman,MDCenters for Disease Control and Prevention
AppendixA:Contributors
Centers for Disease Control and Prevention and the Alzheimer’s Association | ��
Additional ContributorsAveryspecialthankyoutoallofthemenandwomenwhoprovidedfeedbackontherecommendations.
RobertBlancato,MPAMatz, Blancato & Associates, Inc
AmyR.Borenstein,PhDUniversity of South Florida
JohnC.S.Breitner,MD,MPHUniversity of Washington
CarolBryant,PhDUniversity of South Florida
CarlCaspersen,PhDCenters for Disease Control and Prevention
WojtekChodzko-Zajko,PhDUniversity of Illinois at Urbana-Champaign
JamesCooper,MDGeorge Washington University School of Medicine
CarlCotman,PhDInstitute for Brain Aging and Dementia University of California at Irvine
RodDishman,PhDUniversity of Georgia
CharlesF.Emery,PhDOhio State University
PaulEstabrooks,PhDKaiser Permanente-Colorado
JenniferL.Etnier,PhDUniversity of North Carolina at Greensboro
DenisA.Evans,MDRush Institute for Healthy Aging Rush University
JeffFinnAmerican Society on Aging
PatrickFox,PhDInstitute for Health & Aging University of California at San Francisco
MaryGanguli,MD,MPHUniversity of Pittsburgh School of Medicine
FrancineGrodstein,ScDHarvard Medical School
BradleyD.Hatfield,PhDUniversity of Maryland
MichaelJohnsonOB*C Group, LLC
ArthurKramer,PhDBeckman Institute University of Illinois at Urbana-Champaign
DarwinLabarthe,MD,MPH,PhDCenters for Disease Control and Prevention
MichaelW.Link,PhDCenters for Disease Control and Prevention
NancyB.EmersonLombardo,PhDBoston University School of Medicine
EdwardMcAuley,PhDUniversity of Illinois at Urbana-Champaign
GuyMcKhann,MDThe Zanvyl Krieger Mind/Brain Institute Johns Hopkins University
ToniP.Miles,MD,PhDUniversity of Louisville
MarkMoss,PhDBoston University School of Medicine
MarciaOry,PhD,MPHThe Texas A&M University System Health Science Center
RonaldC.Petersen,PhD,MDMayo Clinic College of Medicine
ScottL.ParkinNational Council on Aging
TomProhaska,PhDThe Center for Research on Health and Aging Research and Policy Centers University of Illinois at Chicago
StephanieRamseyCenters for Disease Control and Prevention
GeorgeW.Rebok,PhDJohns Hopkins University
WalterA.Rocca,MD,MPHMayo Clinic College of Medicine
KenRockwood,MD,FRCPCDalhousie University
GailShearerConsumers Union
PhillipD.Tomporowski,Ph.D.University of Georgia
TerrieFoxWetle,PhDBrown University
PeterZandi,PhD,MPH,MHSJohns Hopkins University
StaffLindsayAbraham,MPHNorthrop Grumman/ Centers for Disease Control and Prevention
MarkConnerNorthrop Grumman/ Centers for Disease Control and Prevention
KristineL.Day,MPHCenters for Disease Control and Prevention
SheilaJack,MUP,MSJAlzheimer’s Association
BrendaPepeConcept Systems, Inc.
PeterReed,PhD,MPHAlzheimer’s Association
WalkerTisdale,MPHAlzheimer’s Association
SusanToal,MPHPublic Health Writer/Editor
CatherineVanBrunschotConcept Systems, Inc.
AppendixA:Contributors
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Centers for Disease Control and Prevention and the Alzheimer’s Association|��
��|TheHealthyBrainInitiative: ANationalPublicHealthRoadMaptoMaintainingCognitiveHealth
1 EisendrathSJ,FederA.Themindandsomaticillness:psychologicalfactorsaffectingphysicalillness.In:GoldmanHH,editor.Review of general psychiatry.4thed.Norwalk(CT):AppletonandLange,1995:13–9.
2 NationalResearchCouncil.The aging mind: opportunities in cognitive research.Washington(DC):NationalAcademyPress,2000.
3 HendrieHC,AlbertMS,ButtersMA,etal.TheNIHCognitiveandEmotionalHealthProject,ReportoftheCriticalEvaluationStudyCommittee.Alzheimers Dement 2006;2:12-32.
4 HimesC,OettingerEN,KennyDE.Aging in stride: plan ahead, stay connected, keep moving.Washington(DC):CaresourceHealthcareCommunications,Inc.,2004.
5 HeronMP,SmithBL.Deaths:leadingcausesfor2003.Nationalvitalstatisticsreports;vol55no10.Hyattsville(MD):NationalCenterforHealthStatistics,2007.
6 HendrieHC,AlbertMS,ButtersMA,etal.TheNIHCognitiveandEmotionalHealthProject,ReportoftheCriticalEvaluationStudyCommittee.Alzheimers Dement2006;2:12-32.
7 AdministrationonAging.A profile of older Americans: 2005.Washington(DC):DepartmentofHealthandHumanServices.Availableat:http://www.aoa.gov/PROF/Statistics/profile/2005/3.asp.
8 ASA-MetLifeFoundation.Attitudes and awareness of brain health poll. SanFrancisco:AmericanSocietyonAging,2006.Availableat:http://www.asaging.org/asav2/mindalert/brainhealthpoll.cfm.
9 CutlerNE,WhitelawNW,BeattieBL.American perceptions of aging in the 21st century.Washington(DC):NationalCouncilontheAging,2002.
10 Research!America.American speaks: poll data summary. Volume 7. Alexandria(VA);Research!America,2006.Availableat:http://www.researchamerica.org/publications/AmericaSpeaks/AmericaSpeaksV7.pdf.
11 KhachaturianZS,KhachaturianAS. Publichealthpremisefornationalresearchpriorities:mortalityversusdisability.Alzheimers Dement 2005;1:20-4.
12 HeronMP,SmithBL.Deaths:leadingcausesfor2003. Nat Vital Stat Rep 2007;55:1-92.
13 HebertLE,ScherrPA,BieniasJL,BennettDA,EvansDA.AlzheimerdiseaseintheU.S.population:prevalenceestimatesusingthe2000Census.Archives of NeurologyAugust2003;60:1119-22.
14 GrahamJE,RockwoodK,BeattieBL,etal.Prevalenceandseverityofcognitiveimpairmentwithandwithoutdementiainanelderlypopulation.Lancet 1997;349:1793-6.
15 LopezOL,KullerLH,FitzpatrickA,IvesD,BeckerJT,BeauchampN.Evaluationofdementiainthecardiovascularhealthcognitionstudy.Neuroepide-miology 2003;22:1-12.
16 UnverzagtFW,GaoS,BaiyewuO,etal.Prevalenceofcognitiveimpairment:datafromtheIndianapolisStudyofHealthandAging.Neurology2001;57:1655-62.
17 TheLewinGroupandAlzheimer’sAssociation.Saving lives, saving money: dividends for Americans investing in Alzheimer’s research.Washington(DC):Alzheimer’sAssociation,2003.
18 BynumJPW,RabinsPV,WellerWE,NiefeldM,AndersonGF,WuA.TheimpactofdementiaandchronicillnessonMedicareexpendituresandhospitaluse.JAm Geriatr Soc2004;52:187-94.
19 KhachaturianZS,KhachaturianAS.Publichealthpremisefornationalresearchpriorities:mortalityversusdisability.Alzheimers Dement2005;1:20-4.
20 NationalAllianceforCaregivingandAARP.Caregiving in the US. April2004.Availableat:http://www.caregiving.org/data/04finalreport.pdf.
21 Prigerson HG. Coststosocietyoffamilycaregivingforpatientswithend-stageAlzheimer’sdisease.N Engl JMed 2003;349:1891-2.
22 Schulz R,MendelsohnAB,HaleyWE,MahoneyD,AllenRS,ZhangS,ThompsonL,BelleSH.ResourcesforenhancingAlzheimer’scaregiverhealthinvestigators.End-of-lifecareandtheeffectsofbereavementonfamilycaregiversofpersonswithdementia.N Engl J Med 2003;349:1936-43.
23 Alzheimer’sAssociation:25yearsofsupportingscienceandshapingtheAlzheimerResearchAgenda.Alzheimers Dement2005;1.
24 ASA-MetLifeFoundation.Attitudes and awareness of brain health poll. SanFrancisco:AmericanSocietyonAging,2006.Availableat:http://www.asaging.org/asav2/mindalert/brainhealthpoll.cfm.
25 ASA-MetLifeFoundation.Attitudes and awareness of brain health poll.,SanFrancisco:AmericanSocietyonAging,2006.Availableat:http://www.asaging.org/asav2/mindalert/brainhealthpoll.cfm.
26 ASA-MetLifeFoundation.Attitudes and awareness of brain health poll. SanFrancisco:AmericanSocietyonAging,2006.Availableat:http://www.asaging.org/asav2/mindalert/brainhealthpoll.cfm.
27 Research!America.American speaks: poll data summary. Volume 7. Alexandria(VA);Research!America,2006.Availableat:http://www.researchamerica.org/publications/AmericaSpeaks/AmericaSpeaksV7.pdf.
28 Prigerson HG. Coststosocietyoffamilycaregivingforpatientswithend-stageAlzheimer’sdisease.N Engl J Med2003;349:1891-2.
29 TheLewinGroupandAlzheimer’sAssociation.Saving lives, saving money: dividends for Americans investing in Alzheimer’s research.Washington(DC):Alzheimer’sAssociation,2003.
30 BynumJPW,RabinsPV,WellerWE,NiefeldM,AndersonGF,WuA.TheimpactofdementiaandchronicillnessonMedicareexpendituresandhospitaluse.Am Geriatr Soc 2004;52:187-94.
Centers for Disease Control and Prevention and the Alzheimer’s Association| ��
AppendixB:References
AppendixB:References
31 KoppelR,theAlzheimer’sAssociation.Alzheimer’s disease: the costs to US business in 2002.Washington(DC):Alzheimer’sAssociation;2002.
32 HendrieHC,AlbertMS,ButtersMA,etal.TheNIHCognitiveandEmotionalHealthProject,ReportoftheCriticalEvaluationStudyCommittee.Alzheimers Dement2006;2:12-32
33 AlbertMS,BrownDR,BuchnerD,etal.Thehealthybrainandouragingpopulation:translatingsciencetopublichealthpractice.Alzheimers Dement2007;3(suppl1):S3-S5.
34 WilsonRS,ScherrPA,HogansonG,BieniasJL,EvansDA,BennettDA. EarlylifesocioeconomicstatusandlateliferiskofAlzheimer‘sdisease.Neuroepidemiology2005:25:8-14.
35 WinslowCE.Publichealthatthecrossroads.1926.Am J of Public Health 1999;89:1645-8.
36 InstituteofMedicine,DivisionofHealthCareServices,CommitteefortheStudyoftheFutureofPublicHealth.The future of public health.Washington(DC):NationalAcademyPress,1998.
37 CentersforDiseaseControlandPrevention.Tengreatpublichealthachievements–UnitedStates,1900-1999.MMWR Weekly1999;48(12):241-243.
38 AndersonN.Startgettingpacked:wearemovingtothenextfrontier.Outlook1999(Spring);9.
39 OrleansCT.Helpingpregnantsmokersquit:meetingthechallengeinthenextdecade.Tobacco Control 2000;9(supple3):III6-III11.
40 U.S.DepartmentofHealthandHumanServices.Healthy People 2010: understanding and improving health.2nded.Washington,DC:U.S.GovernmentPrintingOffice,November2000.Availableat:www.healthypeople.gov.
41 U.S.CensusBureau2004b.U.S. interim projections by age, sex, race, and hispanic origin.Availableat:http://www.census.gov/ipc/www/usinterimproj/.
42 ThackerSB.Historicaldevelopment.In:TeutschSM,ChurchillRE,editors.Principles and practice of public health surveillance. 2nded.NewYork:OxfordUniversityPress,2000.
43 BuehlerJW.Surveillance.In:RothmanKJ,GreenlandS.,editorsModern epidemiology,2nded.Philadelphia:Lippencott-Raven,1998.
44 TeutschSM,ThackerSB.Planningapublichealthsurveillancesystem.Epidemiological Bull.1995;16:1-6.
45 KaneM,TrochimWMK.Concept mapping for planning and evaluation.ThousandOaks(CA):SagePublicationsLtd.,2007.
46 OnlineinputwasconductedbyCSGlobal© andanalysisofresultsbyTheConceptSystemCoreversion4.0©.
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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 people’s health and safety, provide reliable health information, and improve health through strong partnerships. CDC’s mission is to promote health and quality of life by preventing and controlling disease, injury, and disability.
Alzheimer’s Association
The Alzheimer’s Association is the leading voluntary health organization in Alzheimer care, support and research. Our mission is to eliminate Alzheimer’s 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 Alzheimer’s.