Novel Intervention Markedly Slows Cognitive Decline in MCI

Pauline Anderson

September 10, 2018

A novel intervention that uses goal setting to promote a more active lifestyle significantly slows cognitive and functional decline in older black patients with mild cognitive impairment (MCI), new research shows.

Investigators found behavioral activation reduced the risk for cognitive decline by more than 87% compared with a supportive therapy approach that involved open-ended discussions.

"This is a very low-cost, low-risk intervention," study investigator Robin J. Casten, PhD, professor, Department of Psychiatry and Human Behavior, Thomas Jefferson University, Philadelphia, Pennsylvania, told Medscape Medical News

Dr Robin J. Casten

"There would be no harm in emphasizing to patients the importance of engaging in specific activities to preserve their brain."

However, Casten doesn't believe recommendations for clinical practice should be based solely on this one study.

The study was published online September 10 in JAMA Neurology.

Higher Rate of Dementia

African Americans have double the rate of dementia compared with whites. Possible reasons for this include the increased risk for hypertension and diabetes in this population, but multiple pathways may be underlying the increased dementia rate, said Casten.

Some research suggests that remaining active and engaged prevents the cognitive decline that may lead to dementia.

The study included 221 black participants aged at least 65 years (mean age, 75.8 years) with MCI. Of these, 79% were women, a rate that is high but typical for such studies, said Casten.

"I don't know whether that's because women live longer or are just more receptive to volunteering to be in psychological or behavioral studies."

Participants were randomly assigned to "behavioral activation" or "supportive therapy."

Behavioral activation, which Casten said has had a good deal of success in treating depression, uses goal setting and action plans to reinforce healthy cognitive, physical, or social activity.

Action plans rely on such things as visual cues, written schedules, and step-by-step sequencing to compensate for cognitive deficits.

An action plan for walking with a buddy might, for example, include calling that friend after lunch, picking a time to meet, and recording the date on the calendar.

If study participants didn't meet their self-defined goals, trained community health workers helped them break down these goals to smaller, actionable steps. This, said Casten, helped remove obstacles and reduce feelings of "being overwhelmed."

She emphasized the importance of the intervention being culturally sensitive in order to remove mistrust.

"We knew from the literature and focus groups that these subjects prefer to work with black healthcare providers."

African American Population

Staff were all African American, and all education materials were targeted to this racial group.

The control group in the study received supportive therapy, a structured psychological treatment that facilitates personal expression and conveys empathy, respect, and optimism. Open-ended discussions with a community health worker focused on the experience of aging, memory loss, illness, disability, and social isolation.

Both groups received five in-home 60-minute treatment sessions over 4 months followed by six in-home 60-minute maintenance sessions over the next 20 months.

The main difference between the two groups was that the active intervention included goal-setting and the controls did not.

"At the end of the day, we wanted to know if people do better on memory tests because they were engaging in activities, not because this nice person was going out to their home pretty frequently and giving them lots of attention," said Casten.

To assess cognition, researchers used the Hopkins Verbal Learning Test–Revised (HVLT-R), a 12-item word list test. The total recall score (from 0 to 36) is the sum of three learning trials and represents learning and working memory.

They also used the National Alzheimer Coordinating Center's uniform data set, a neuropsychological battery that includes memory and other cognitive tests.

The primary outcome was a decline of six or more recalled words on the HVLT-R total recall score at 24 months.

To assess function, researchers used the University of California Performance-Based Skills Assessment. This tool tests the accuracy of such tasks as writing checks, making change, using a telephone, and scheduling a physician appointment. Higher scores indicate better function.

Progression to dementia was defined as a decline of 6 or more on the HVLT-R and a University of California Performance-Based Skills Assessment score indicating dementia at 24 months.

Casten noted that researchers based their determination of cognitive decline on neuropsychiatric testing and didn't use clinical interviews, medical histories, or conversations with significant others. Assessors were blinded to treatment allocation.

Slower Rate of Cognitive Decline

The 2-year trial was completed by 69.4% of the behavioral activation group and 79.1% of the supportive therapy group.

The researchers aren't certain why more in the active group dropped out of the study, said Casten. But she speculated that participants might have felt shame or embarrassment if they failed to complete assignments they had given themselves — whether it was to complete a particular number of crossword puzzles every week or walk a certain number of steps every day.

At 24 months, the estimated rate of cognitive decline was 1.2% (95% confidence interval [CI], 0.2% - 6.4%) in the behavioral activation group compared with 9.3% (95% CI, 5.3% - 16.4%) in the supportive therapy group (relative risk, 0.12; 95% CI, 0.02 - 0.74; P = .02).

Behavioral activation participants had pretty stable function scores over time (slope of −0.13; 95% CI, −2.05 to 1.79; P = .89), whereas scores of supportive therapy participants declined.

This is an important finding because "ultimately, that's the tipping point that may push somebody to a diagnosis of dementia," said Casten.

Among behavioral activation participants, 4.4% progressed to dementia after 6 months vs 8.4% of supportive therapy participants (P = .25).

Behavioral activation participants had significant annual improvement in executive function. For example, for the Trail Making Test, part B, the slope was −13.5 (95% CI, −21.4 to −5.52; P < .001). No improvement occurred in the supportive therapy group.

Serious adverse events included falls (13% in the active group vs 25% in controls), emergency department visits (22% vs 22%), hospitalizations (32% vs 28%), and deaths (5% vs 4%). Between-group differences were not significant.

The researchers found no indication that sex was related to treatment outcomes, said Casten. However, men were more likely to drop out.

In light of this new study, clinicians might want to consider getting patients to establish and follow a schedule. This, said Casten, "might help them shoot down barriers to doing crossword puzzles, exercising, socializing, or whatever."

Important New Evidence

Commenting on the findings for Medscape Medical News, Ralph L. Sacco, MD, professor, Olemberg Chair of Neurology, and executive director, McKnight Brain Institute, University of Miami, Florida, and president of the American Academy of Neurology, said the study "provides important evidence for the efficacy of behavioral activation" in slowing cognitive decline among older blacks with amnestic MCI.

Sacco noted that evidence-based reviews by the National Academy of Medicine and the American Academy of Neurology suggest that behavioral interventions "show the most promise for preventing dementia or slowing cognitive aging."

Multimodal interventions, such as behavior activation, may be even more effective than cognitive or physical activity alone, said Sacco.  

In addition, because African Americans are at a greater risk for dementia, "any intervention that can be easily implemented could have a great public health impact," he added.

For additional comment, Medscape Medical News approached Ronald Petersen, MD, PhD, director, Mayo Clinic Alzheimer's Disease Research Center in Rochester, Minnesota, and the Mayo Clinic Study of Aging.

Petersen said he found the study "intriguing" and suggested that a larger study should be carried out in this population.

While the intervention appeared to work, "it was single-blinded and there was attrition," noted Petersen. 

"Nevertheless, it is encouraging that behavioral interventions may be beneficial in these participants."

Casten, Sacco, and Petersen have disclosed no relevant financial relationships.

JAMA Neurol. Published online September 10, 2018. Full text

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