Sharp Brains: Brain Fitness and Cognitive Health News

Apr 29, 2010

Alzheimer’s Disease Prevention or Cognitive Enhancement?

By: Alvaro Fernandez

An inde­pen­dent alzheimersexpert panel orga­nized by the NIH released yes­ter­day a thought­ful report on the state of the sci­ence for pre­ven­tion of Alzheimer’s Dis­ease and cog­ni­tive decline. The report, avail­able here, sum­ma­rizes the panel’s review by saying:

  • “Firm con­clu­sions can­not be drawn about the asso­ci­a­tion of mod­i­fi­able risk fac­tors with cog­ni­tive decline or Alzheimer’s disease.”
  • “There is insuf­fi­cient evi­dence to sup­port the use of phar­ma­ceu­ti­cal agents or dietary sup­ple­ments to pre­vent cog­ni­tive decline or Alzheimer’s dis­ease. How­ever, ongo­ing addi­tional stud­ies includ­ing (but not lim­ited to) anti-hypertensive med­ica­tions, omega-3 fatty acid, phys­i­cal activ­ity, and cog­ni­tive engage­ment may pro­vide new insight into the pre­ven­tion or delay of cog­ni­tive decline or Alzheimer’s disease.”

To put find­ings in per­spec­tive, let me sug­gest our arti­cle Brain main­te­nance: it’s about cog­ni­tive enhance­ment first, Alzheimer’s delay sec­ond. Before peo­ple get scared away by the sen­tence “there is noth­ing we know of that can pre­vent Alzheimer’s Dis­ease”, every­one should under­stand that this is true but dif­fer­ent from say­ing “there is noth­ing we can do to reduce the prob­a­bil­ity from devel­op­ing AD symp­toms” or “there is noth­ing we can do today to enhance our cog­ni­tive func­tions today and tomor­row” (both areas with solid research and use­ful guide­lines and tools). I gave a talk yes­ter­day dur­ing the San Fran­cisco Mini Med­ical School orga­nized by Cal­i­for­nia Pacific Med­ical Center/ Sut­ter Health, and mak­ing this dis­tinc­tion clear was in fact my main point.

The report pro­vides great read­ing and sev­eral excel­lent rec­om­men­da­tions for future research, includ­ing sev­eral areas we iden­ti­fied dur­ing the Jan­u­ary Sharp­Brains Sum­mit as areas where database-driven auto­mated cog­ni­tive assess­ments are likely to add much value both to research and to clin­i­cal prac­tice in years to come:

  • “An objec­tive and consensus-based def­i­n­i­tion of mild cog­ni­tive impair­ment needs to be devel­oped, includ­ing iden­ti­fi­ca­tion of the cog­ni­tive areas of impair­ment, the rec­om­mended cog­ni­tive mea­sures for assess­ment, and the degree of devi­a­tion from nor­mal to meet diag­nos­tic cri­te­ria. This con­sis­tency in def­i­n­i­tion and mea­sure­ment is impor­tant to gen­er­ate stud­ies that can be pooled or com­pared to bet­ter assess risk fac­tors and pre­ven­tive strate­gies for cog­ni­tive decline and Alzheimer’s disease.”
  • “A stan­dard­ized, well-validated, and cul­tur­ally sen­si­tive bat­tery of out­come mea­sures needs to be devel­oped and used across research stud­ies to assess rel­e­vant domains of cog­ni­tive func­tion­ing in a man­ner that is appro­pri­ate for the func­tional level of the pop­u­la­tion sam­ple being stud­ied (e.g., cog­ni­tively nor­mal, mild cog­ni­tive impair­ment); and age-gender spe­cific norms need to be estab­lished for com­par­i­son and objec­tive assess­ment of dis­ease sever­ity. We rec­om­mend a com­pre­hen­sive approach to out­comes assess­ment that accounts for the impact of cog­ni­tive decline on other mul­ti­ple domains of func­tion and qual­ity of life that may be affected by deficits in cog­ni­tion (for exam­ple, emo­tional and phys­i­cal func­tion­ing) of both the affected per­son and his or her pri­mary caregiver.”
  • “A sim­ple, inex­pen­sive, quan­ti­ta­tive instru­ment to assess mild cog­ni­tive impair­ment, which can be admin­is­tered in a repeated man­ner by trained (non-expert) staff in both the pri­mary care office and the research/specialty clinic, needs to be estab­lished. This instru­ment should be sen­si­tive to changes over time across a wide range of cog­ni­tive abil­i­ties and social, cul­tural, and lin­guis­tic back­grounds. The devel­op­ment and wide­spread imple­men­ta­tion of this instru­ment is essen­tial to enable bet­ter research.”

To read report: click Here

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6 Responses

  1. Richard says:
    April 30, 2010 at 12:25

    It would be great to decrease Alzheimers cases a lot. Med­i­ta­tion helps but peo­ple aren’t open enough to it. I don’t want to end up men­tally unsta­ble at 65 so I’m get­ting ahead now!

  2. Michael C. Patterson says:
    April 30, 2010 at 8:26

    I attended the first two days of the NIH con­fer­ence. Frankly, I think the panel report mis­rep­re­sents the research and does a great dis­ser­vice to the field. Their head­line — that there is no cur­rent evi­dence of even mod­er­ate sci­en­tific qual­ity sup­port­ing the asso­ci­a­tion of any mod­i­fi­able fac­tor … with reduced risk of Alzheimer’s Dis­ease — is sim­ply wrong. True, decades of research have failed to find a cure for AD. Phar­ma­ceu­ti­cal approaches have yet to work. But there is a grow­ing body of solid evi­dence that behav­ioral and lifestyle inter­ven­tions, such as phys­i­cal exer­cise, men­tal exer­cise and social engage­ment, par­tic­u­larly when done in com­bi­na­tion with each other, do have a pos­i­tive effect on cog­ni­tive decline and even the progress of AD. We need to be telling the pub­lic — as you do at Sharp­brains — that there is solid evi­dence that healthy behav­iors can improve brain health and slow cog­ni­tive decline and the onset of dementia.

  3. Alvaro Fernandez says:
    April 30, 2010 at 5:29

    Hello Michael,

    I don’t think it “mis­rep­re­sents” the research — what you are say­ing is con­sis­tent with what they are say­ing, you are each focus­ing on a dif­fer­ent part of the puz­zle. They could have com­mu­ni­cated things bet­ter, putting things in at least some per­spec­tive by, for exam­ple, explain­ing cog­ni­tive reserve.

    The prob­lem is that we some­how seem to equate “there’s noth­ing proven to pre­vent Alzheimer’s” with “there’s noth­ing I can do to maintain/ enhance my cog­ni­tive fit­ness”. Those are 2 com­pletely sep­a­rate out­comes (that obvi­ously influ­ence each other), but we should all under­stand that they are sep­a­rate out­comes; there­fore, there are dif­fer­ent tools and areas of research involved.

    Think about like phys­i­cal fit­ness — peo­ple today under­stand phys­i­cal fit­ness is an out­come in itself for a vari­ety of rea­sons, beyond the very impor­tant pub­lic health role it plays in preventing/ low­er­ing risk of dis­eases. Even if the report says that phys­i­cal exer­cise doesn’t have strong sci­en­tific evi­dence as a way to pre­vent Alzheimer’s…aren’t there many other rea­sons to engage in phys­i­cal exercise?

    I believe mak­ing this dis­tinc­tion clear would help edu­cate and encour­age the pub­lic and pro­fes­sion­als to adopt/ pro­mote bet­ter mind­sets & behav­iors, and also help accel­er­ate research (in fact, I like many of the rec­om­men­da­tions because they seem to go in pre­cisely that direction).

    Also, there is a dif­fer­ence between “noth­ing has been shown to pre­vent Alzheimer’s” (what they are say­ing, and good rep­re­sen­ta­tion of research) and “there’s noth­ing I can do to lower the prob­a­bil­ity of devel­op­ing Alzheimer’s symp­toms” (which they are NOT say­ing, because it wouldn’t be true based on what we know).

    At the end of the day, as indi­vid­u­als I think we would all be bet­ter served by think­ing about neu­ro­plas­tic­ity more as an invi­ta­tion to life­long cog­ni­tive devel­op­ment and main­te­nance rather than as a “pre­ven­tion” of dis­ease (even if it will obvi­ously brings pub­lic health ben­e­fits too, at the pop­u­la­tion level).

    Was there a con­ver­sa­tion about all this when you were there? I saw that Yaakov Stern and Art Kramer were among speak­ers, haven’t talked to them.

  4. Jenny Brockis says:
    April 30, 2010 at 6:55

    I was lis­ten­ing to Pro­fes­sor Ralph Mar­tins from the McCusker Unit for Alzheimer’s Dis­ease Research on radio this week. One of his main points was exactly as you have stated, that we do need to focus on the lifestyle inter­ven­tions to build cog­ni­tive reserve.

  5. Steve Zanon says:
    May 9, 2010 at 11:54

    In the intro­duc­tions on day one of the NIH con­fer­ence Jenifer Croswell from OMAR out­lined three dif­fer­ent frames of ref­er­ence and deci­sion mak­ing in this con­text. She men­tioned (1) the indi­vid­ual and fam­ily based on per­sonal val­ues, (2) com­mu­nity doc­tors affect­ing their patients, and (3) rec­om­men­da­tions for an entire pop­u­la­tion of peo­ple which should only con­tain strong evi­den­tiary based infor­ma­tion. She indi­cated that this con­fer­ence would pro­duce a state­ment based on the third con­text and in that respect the panel has done a great job in high­light­ing the gaps that gov­ern­ment, indus­try & research need to focus on in order to most effec­tively move forward.

    How­ever some good news for indi­vid­u­als did come out of the con­fer­ence. Pages 7 & 8 of the “Sys­tem­atic Evi­dence Review” (http://www.ahrq.gov/clinic/tp/alzcogtp.htm) pro­vides a great snap­shot of all the asso­ci­ated fac­tors con­sid­ered at the con­fer­ence and their cur­rent sta­tus in terms of level of evi­dence. This doc­u­ment sum­marises the research from 25 sys­tem­atic reviews and 250 pri­mary research stud­ies which were fil­tered from searches that located 6907 cita­tions. The stud­ies were eval­u­ated for eli­gi­bil­ity and qual­ity, and data were abstracted on study design, demo­graph­ics, inter­ven­tion or pre­dic­tor fac­tor, and cog­ni­tive out­comes. The final report was peer reviewed. In terms of inde­pen­dence and weight of evi­dence this doc­u­ment is likely to pro­vide the strongest posi­tion on the sub­ject that we have today.

    If we under­stand that all this evi­dence is still build­ing but clearly has strong direc­tion then I believe it is a good base­line (as of today) from which indi­vid­u­als may begin to make lifestyle choices. Of course as research pro­gresses the base­line will change but for now I think it is a solid foun­da­tion from which to work. Per­sonal pref­er­ences would guide choices but where the direc­tion of asso­ci­a­tion is cat­e­gorised as .….
    •“no evi­dence” we should prob­a­bly con­sider ignor­ing
    •“inad­e­quate evi­dence” we should prob­a­bly con­sider treat­ing as sus­pi­cious
    •“increas­ing or decreas­ing risk” we should prob­a­bly con­sider to be strongly asso­ci­ated (but not defin­i­tive) and there­fore offer­ing promis­ing (but not cer­tain) lifestyle choices

    So with any good risk man­age­ment strat­egy our best bet is to diver­sify risk across sev­eral of the most likely fac­tors. The “Sys­tem­atic Evi­dence Review” clearly iden­ti­fies the most likely risk fac­tors. We don’t have cer­tainty but we do have direc­tion and I think that is an encour­ag­ing mes­sage for the public.

    The good news for those inter­ested in brain train­ing is that in the find­ings for cog­ni­tive decline (page 8), cog­ni­tive train­ing has the high­est level of evidence.

  6. Alvaro Fernandez says:
    May 14, 2010 at 4:02

    Steve, thank you for tak­ing the time to share this with us, had missed that level of detail.

    The Amer­i­can Soci­ety of Aging asked me for an arti­cle on the topic, which I assume will become avail­able online at some point and I will link to it. I will repub­lish your com­ment as a blog post so that more read­ers can ben­e­fit from it.

    Thanks!

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