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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
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PREVENTING COGNITIVE DECLINE
AND DEMENTIA

A WAY FORWARD

Committee on Preventing Dementia and Cognitive Impairment

Alan I. Leshner, Story Landis, Clare Stroud, and Autumn Downey,
Editors

Board on Health Sciences Policy

Health and Medicine Division

A Consensus Study Report of

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THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by Contract No. HHSN26300074 with the U.S. Department of Health and Human Services’ National Institutes of Health through the National Institute on Aging. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-45959-4
International Standard Book Number-10: 0-309-45959-1
Digital Object Identifier: https://doi.org/10.17226/24782
Library of Congress Control Number: 2017950614

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Copyright 2017 by the National Academy of Sciences. All rights reserved.

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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2017. Preventing cognitive decline and dementia: A way forward. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24782.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
×

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The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president.

The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
×

Image

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task.

Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies.

For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
×

COMMITTEE ON PREVENTING DEMENTIA AND COGNITIVE IMPAIRMENT

ALAN I. LESHNER (Chair), CEO Emeritus, American Association for the Advancement of Science

STORY LANDIS (Vice Chair), Director Emerita, National Institute of Neurological Disorders and Stroke

MARILYN ALBERT, Professor of Neurology, Director of the Division of Cognitive Neuroscience, Johns Hopkins University School of Medicine

LISA L. BARNES, Professor of Neurological Sciences and Behavioral Sciences, Director of the Rush Center of Excellence on Disparities in HIV and Aging, Rush University Medical Center

DAN G. BLAZER, J.P. Gibbons Professor of Psychiatry Emeritus, Duke University Medical Center

MARK A. ESPELAND, Professor of Biostatistical Sciences, Wake Forest School of Medicine

J TAYLOR HARDEN, Executive Director, National Hartford Center of Gerontological Nursing Excellence

CLAUDIA H. KAWAS, Professor of Neurology, Professor of Neurobiology and Behavior, University of California, Irvine

NAN M. LAIRD, Harvey V. Fineberg Research Professor of Public Health, Harvard University

KENNETH M. LANGA, Cyrus Sturgis Professor of Medicine, University of Michigan and Veterans Affairs Ann Arbor Healthcare System

ERIC B. LARSON, Vice President, Research and Health Care Innovation, Kaiser Foundation Health Plan of Washington

JOSÉ A. LUCHSINGER, Florence Irving Associate Professor of Medicine, Associate Professor of Epidemiology, Columbia University

RONALD C. PETERSEN, Professor of Neurology, Cora Kanow Professor of Alzheimer’s Disease Research, Mayo Clinic College of Medicine

RALPH L. SACCO, Professor and Olemberg Chair of Neurology, Executive Director of the McKnight Brain Institute, University of Miami; Chief of Neurology, Jackson Memorial Hospital

SUDHA SESHADRI, Professor of Neurology, Boston University School of Medicine

LESLIE B. SNYDER, Professor of Communication, University of Connecticut

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
×

KRISTINE YAFFE, Professor of Psychiatry, Neurology, and Epidemiology and Biostatistics, Vice Chair for Clinical and Translational Research, Roy and Marie Scola Endowed Chair, University of California, San Francisco

Study Staff

CLARE STROUD, Study Director (until April 2017)

AUTUMN DOWNEY, Study Director (since April 2017)

SHEENA M. POSEY NORRIS, Program Officer

BENJAMIN KAHN, Research Associate

OLIVIA YOST, Research Associate

DANIEL FLYNN, Senior Program Assistant

ANDREW POPE, Director, Board on Health Sciences Policy

National Academy of Medicine Gilbert S. Omenn Fellow

JAMES BURKE, Assistant Professor of Neurology, University of Michigan Medical School

Consultants

LISA BAIN, Consultant Writer

RONA BRIERE, Senior Editor, Briere Associates, Inc.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
×

REVIEWERS

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

Carol Brayne, University of Cambridge

Steven T. DeKosky, University of Florida College of Medicine

Rebecca Gottesman, Johns Hopkins University School of Medicine

Francine Grodstein, Brigham and Women’s Hospital

David E. Housman, Massachusetts Institute of Technology

Caryn Lerman, University of Pennsylvania

Roger J. Lewis, Harbor-UCLA Medical Center

Martha C. Morris, Rush Medical College

Brenda Plassman, Duke University Medical Center

Patricia Reuter-Lorenz, University of Michigan

Mary Sano, Icahn School of Medicine at Mount Sinai and the James Peters Veterans Affairs Medical Center

Shekhar Saxena, World Health Organization

Brian Southwell, RTI International

Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
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William Thies, Alzheimer’s Association

Joe Verghese, Albert Einstein College of Medicine

Keith E. Whitfield, Wayne State University

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by Enriqueta C. Bond, Burroughs Wellcome Fund, and Huda Akil, University of Michigan. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
×

PREFACE

The prospect of potential cognitive decline and the development of dementia is a significant source of anxiety for many people as they age, raising deep concerns about their future independence and quality of life. Yet for those interested in taking active steps to maintain, to the extent possible, their brain health, it is difficult to know how best to invest their time and resources. A bewildering number of products and behaviors have been touted as potential preventive measures, but very few have been subjected to rigorous testing for effectiveness. Recognizing that many people turn to the National Institute on Aging (NIA) of the National Institutes of Health for up-do-date information on both normal cognitive decline and neuropathological processes that can occur with aging, NIA asked the National Academies of Sciences, Engineering, and Medicine to convene a committee to examine and comment on the state of knowledge about what works in preventing or slowing cognitive decline and dementia.

This report examines the current state of the evidence on interventions for preventing cognitive decline and dementia and is intended to inform future efforts to develop public health strategies and messages, as well as to suggest future research priorities for improving the quality of the relevant knowledge base. Although the evidence has not yet matured to the level that would support an assertive public health campaign aimed at widespread adoption of any such intervention, the report does identify those interventions, supported by some evidence of benefit, that the committee believes should be discussed with members of the public who are actively seeking advice on steps they can take to maintain brain health as they age. Two key points add important context to the committee’s recommendations.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
×

First, the committee was asked to make its recommendations based largely on the most stringent form of evidence—randomized controlled trials (RCTs). RCTs are the gold standard in evidence generation but require large investments of money and time. Moreover, while they are particularly effective for testing single-intervention solutions, the apparent complexity of the pathophysiology underlying cognitive decline and dementia suggests that a multifaceted approach may be most effective. Such an approach is challenging to evaluate through an RCT. To lend confidence to the suggestions emerging from RCTs, then, the committee considered other salient sources of evidence that, when combined with RCT-based evidence, offer a fuller picture.

Second, it should be emphasized that the committee’s analysis is of necessity based on the current state of knowledge, and addresses a rapidly evolving scientific field. Fundamental understanding of the processes of cognitive decline and dementia is advancing at an impressive pace. Moreover, additional intervention studies were being conducted even as this report was being written, and they are expected to yield important insights. The committee’s suggestions for prioritizing future research, including methodological recommendations, are intended to help shape future research efforts in this domain and generate a more comprehensive and stronger evidence base.

We wish to offer our deep gratitude to the members of this National Academies of Sciences, Engineering, and Medicine committee. Leading such an expert and committed group of scholars, all of whom gave generously of their time, has been an incredibly rewarding experience. This work also benefited greatly from the exceptional competence and dedication of the National Academies staff and many others cited in the acknowledgments that follow.

Alan I. Leshner, Chair
Story Landis, Vice Chair
Committee on Preventing Dementia and Cognitive Impairment

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
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ACKNOWLEDGMENTS

The committee first would like to recognize and honor the contributions of Robert Lewis Kane to this project. Dr. Kane led the work of the Minnesota Evidence-based Practice Center to develop the Agency for Healthcare Research and Quality (AHRQ) systematic review that formed the primary evidence base used by the committee. His leadership and deep knowledge in this area were critical to the development of this extensive, thorough, and thoughtful analysis of interventions for cognitive decline and dementia. Sadly, Dr. Kane died unexpectedly while the committee was writing this report. Dr. Kane was the Minnesota Chair of Aging and Long-Term Care at the University of Minnesota’s School of Public Health, where he had a long and productive career. He was known for his scholarship, his deeply felt advocacy to help individuals age with grace and dignity, his generosity to colleagues and students, and his sense of humor. Among many other important contributions, his work with the Office of Technology Assessment’s Advisory Committee on Alzheimer’s Disease and Related Disorders helped put Alzheimer’s disease “on the map” from the perspective of research, clinical care, and policy. He was a true force in the field and will be greatly missed.

The committee also acknowledges and thanks the study sponsor—the National Institute on Aging—and particularly Richard Hodes, Marie A. Bernard, and Melinda Kelley for their leadership and vision in the development of this project. We are grateful to David Niebuhr, Kim Wittenberg, and colleagues at AHRQ for overseeing the systematic review that formed the primary evidence base used for the study. We also wish to recognize and thank Mary Butler, Howard Fink, and the many others at the Minnesota

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
×

Evidence-based Practice Center who worked with Dr. Kane on the preparation of the AHRQ systematic review.

We wish to express our gratitude to the many individuals who gave presentations to and participated in discussions with the committee. We especially thank Walter Koroshetz (National Institute of Neurological Disorders and Stroke) and William Thies (Alzheimer’s Association) for sharing their insights with the committee during the initial phase of the project, as well as the following workshop presenters: James Appleby (Gerontological Society of America), Matthew Baumgart (Alzheimer’s Association), Michael Ellenbogen (Alzheimer’s disease/dementia advocate), Mary Ann Forciea (University of Pennsylvania and American College of Physicians), Rebecca Gottesman (Johns Hopkins University), Stacy Pagos Haller (BrightFocus Foundation), Julene Johnson (University of California, San Francisco), Brian LeBlanc (Alzheimer’s disease advocate), Sarah Lenz Lock (AARP), Susan McCurry (University of Washington), Regina Davis Moss (American Public Health Association), Edo Richard (Radboud University), Walter Rocca (Mayo Clinic), Mary Sano (Mount Sinai School of Medicine), Lisa Shulman (University of Maryland and American Academy of Neurology), Brian Southwell (RTI International), Joe Verghese (Albert Einstein College of Medicine), Jeff Williamson (Wake Forest Baptist Health), and Sherry Willis (University of Washington).

Finally, the committee would like to express its gratitude to and admiration for the National Academies of Sciences, Engineering, and Medicine staff who worked so hard and so well on the study: Clare Stroud, Autumn Downey, Sheena Posey Norris, Benjamin Kahn, Olivia Yost, and Daniel Flynn. We also are grateful for the contributions of James Burke, Gilbert S. Omenn Fellow at the National Academy of Medicine; Rona Briere, for her careful editing of the report; and Rebecca Morgan of the National Academies Research Center, for her assistance with fact-checking.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
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ACRONYMS AND ABBREVIATIONS

ACCORD-MIND

Action to Control Cardiovascular Risk in Diabetes-Memory in Diabetes trial

ACE

angiotensin converting enzyme

AChEI

acetylcholinesterase inhibitor

ACTIVE

Advanced Cognitive Training for Independent and Vital Elderly trial

ADAS-Cog

Alzheimer’s Disease Assessment Scale-Cognitive Subscale

ADRD

Alzheimer’s disease-related dementias

ADVANCE

Action in Diabetes and Vascular Disease: PreterAx and DiamicroN-MR Controlled Evaluation trial

AHRQ

Agency for Healthcare Research and Quality

ARB

angiotensin receptor blockers

ARCD

age-related cognitive decline

BDNF

brain-derived neurotrophic factor

CATD

clinical Alzheimer’s-type dementia

CBTI

cognitive-behavioral therapy for insomnia

CFAS

Cognitive Function and Ageing Study

CI

confidence interval

COX-2

cyclooxygenase-2

DASH

Dietary Approaches to Stop Hypertension

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
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EPC

evidence-based practice center

EXERT

Exercise in Adults with Mild Memory Problems trial

FINGER

Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability

GRADE

Glycemic Reduction Approaches in Diabetes trial

HOPE-3

Heart Outcomes Prevention Evaluation-3

HRS

Health and Retirement Study

HYVET

Hypertension in the Very Elderly Trial

IADL

instrumental activity of daily living

IHAMS

Iowa Health and Active Minds Study

IOM

Institute of Medicine

LIFE

Lifestyle Interventions and Independence for Elders trial

MAPT

Multidomain Alzheimer’s Prevention Trial

MAX

Mental Activity and Exercise trial

MCI

mild cognitive impairment

MIND

Mediterranean-DASH Intervention for Neurodegenerative Delay

MMSE

Mini Mental State Exam

NIA

National Institute on Aging

NIH

National Institutes of Health

NMDA

N-methyl-D-aspartate

NSAID

nonsteroidal anti-inflammatory drug

ORIGIN

Outcome Reduction with Initial Glargine Intervention

PET

positron emission tomography

PREDIMED

Prevención con Dieta Mediterránea trial

PreDIVA

Prevention of Dementia by Intensive Vascular Care

PROGRESS

Perindopril Protection against Recurrent Stroke Study

Page xvii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preventing Cognitive Decline and Dementia: A Way Forward. Washington, DC: The National Academies Press. doi: 10.17226/24782.
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RCT

randomized controlled trial

REGARDS

Reasons for Geographical and Racial Differences in Stroke study

RR

relative risk

SBP

systolic blood pressure

SCOPE

Study on Cognition and Prognosis in the Elderly

SPRINT

Systolic Blood Pressure Intervention Trial

SSRI

selective serotonin reuptake inhibitor

USPSTF

U.S. Preventive Services Task Force

WHIMS

Women’s Health Initiative Memory Study

WHISCA

Women’s Health Initiative Study of Cognitive Aging

WHO

World Health Organization

Page xviii Cite
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Societies around the world are concerned about dementia and the other forms of cognitive impairment that affect many older adults. We now know that brain changes typically begin years before people show symptoms, which suggests a window of opportunity to prevent or delay the onset of these conditions. Emerging evidence that the prevalence of dementia is declining in high-income countries offers hope that public health interventions will be effective in preventing or delaying cognitive impairments. Until recently, the research and clinical communities have focused primarily on understanding and treating these conditions after they have developed. Thus, the evidence base on how to prevent or delay these conditions has been limited at best, despite the many claims of success made in popular media and advertising. Today, however, a growing body of prevention research is emerging.

Preventing Cognitive Decline and Dementia: A Way Forward assesses the current state of knowledge on interventions to prevent cognitive decline and dementia, and informs future research in this area. This report provides recommendations of appropriate content for inclusion in public health messages from the National Institute on Aging.

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