COMMENTARY

Cognitive Health for an Aging Population

Laura A. Stokowski, RN, MS

Disclosures

November 16, 2009

In This Article

Public Health Directions

The State of Aging and Health in America 2007[35] identified the prevention of cognitive decline as an area where public health can significantly improve quality of life for aging individuals.

Adults now aged 42-60 years -- the baby boomers -- belong to the largest generation in American history. Cognitive health issues may already profoundly affect their parents and grandparents, and will touch huge numbers of boomers themselves in the not-too-distant future. The efforts of the public health community, and indeed, all healthcare providers could enable baby boomers to enter their "golden years" not with fear of losing cognitive capacity and self-reliance, but looking forward to continued productivity, independence, and good quality of life.[35] It is absolutely critical to convey appropriate valid, evidence-based messages about cognitive health now, so that those in midlife may take action not only for themselves but also for their younger and elder family members.[20]

State of the Science

Today's emphasis on brain health may seem new, but it was in fact more than a decade ago that the severity of this looming public health crisis captured the attention of several key divisions of the US National Institutes of Health (the National Institute of Neurological Disorders and Stroke, the National Institute of Mental Health, and the National Institute on Aging. These agencies realized that large-scale programs to improve public health had to be based on science to the extent possible,[21] and so it was imperative to assess the current state of knowledge in the field. In 2001, these 3 institutes embarked on the Healthy Brain Project[36] to gather and summarize pertinent research that would become the foundation for future broad-scale public health initiatives and to highlight weaknesses, contradictions, or gaps in knowledge that might pose barriers to such efforts.

The Cognitive and Emotional Health Project. The primary objective of the Cognitive and Emotional Health Project was to review the longitudinal and epidemiologic research on demographic, social, and biologic determinants of cognitive and emotional health in aging adults, and the pathways by which cognitive and emotional health may reciprocally influence each other. In a critical analysis of the available scientific literature, 4 major areas of evidence were reviewed:

  • Cognitive health: Cognitive health includes the changes in cognitive function that occur with aging, how cognitive abilities can be accurately measured in aging individuals, and the known predictors of age-related cognitive decline.

  • Emotional health: Emotional health is the role of emotions in the etiology of disease, measures of emotional constructs (such as depression, hostility, or stress), and evidence of relationships between emotional constructs and cognitive health.

  • Demographic and social factors: This includes variables that can influence health and the link between these variables and physical and cognitive health.

  • Biomedical and physiologic factors: This includes factors that predict cognitive or emotional health, such as measures of cardiovascular health, adrenal function, immune function, genetics, and so forth. Factors that limit physical activity may in turn affect both emotional and cognitive health.

Translating Science Into Practice. One of the most important questions to arise from these early endeavors was how to bridge the gap between science and practice. How will we translate what we know about cognitive health into usable, practical, and effective recommendations for public health at the community level?

To tackle this daunting task, the Centers for Disease Control and Prevention (CDC), along with the Alzheimer's Association, commenced the Healthy Brain Initiative. Recognizing that the potential interventions for influencing brain health could easily number in the hundreds, the CDC decided to focus on the 2 risk factors for cognitive decline and barriers to cognitive health supported by the strongest science[19]: physical inactivity and vascular disease.

The CDC believed that the professional public health community was already primed to integrate these 2 risk factors, along with appropriate health promotion and risk prevention strategies, into community-based practice. At the same time, they acknowledge that as more studies are completed and the science evolves, different or even previously unconsidered risk factors could assume equal or greater importance.

The Cognitive Health Road Map. The CDC and the Alzheimer's Association also partnered to produce A National Health Road Map to Maintaining Cognitive Health.[37] The Road Map acknowledges the current state of the science, social trends, and other factors that affect cognitive health from a public health perspective with a clear focus on primary prevention and a commitment to eliminate health disparities.

This Road Map comes at a critical time, when scientific interest in cognitive health is beginning to meet the escalating demand of the public for information about maintaining cognitive function.[20] This guidance document is both a call to action and a guide for implementing an effective coordinated approach to moving cognitive health into public health practice.[20]

The Road Map's highest priorities for meeting the public health challenge of cognitive health are found in Table 2. These are the actions that stakeholders hope to accomplish in the next 3-5 years.

Table 2. Cognitive Health Road Map -- Highest Priority Actions

Determine how diverse audiences think about cognitive health and its associations with lifestyle factors.
Disseminate the latest science to increase public understanding of cognitive health and dispel common misconceptions.
Help people understand the connection between risk and protective factors and cognitive health.
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.
Conduct controlled clinical trials to determine the effect of reducing vascular risk factors on lowering the risk for cognitive decline and improving cognitive function.
Conduct controlled clinical trials to determine the effect of physical activity on reducing the risk for cognitive decline and improving cognitive function.
Conduct research on other areas potentially affecting cognitive health, such as nutrition, mental activity, and social engagement.
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.
Initiate policy changes at the federal, state, and local levels to promote cognitive health by engaging public officials.
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.

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