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Article: The Business and Ethics of the Brain Fitness Boom

Dur­ing a debrief­ing after the 2011 Sharp­Brains Sum­mit, Rick Moody, Direc­tor of the Office of Aca­d­e­mic Affairs at AARP, sug­gested that we should con­tribute a thought-leadership piece to a spe­cial issue on brain health for one of their pro­fes­sional pub­li­ca­tions by the Amer­i­can Soci­ety on Aging. You can now read the result­ing arti­cle, writ­ten by our cofounder Alvaro Fernandez:

  • Open nicely for­mat­ted arti­cle by click­ing Here (opens PDF document).
  • Or, sim­ply read below.

The Busi­ness and Ethics of the

Brain Fit­ness Boom

The recent dis­cov­ery that expe­ri­ence can change brain struc­ture and func­tion at any age has sparked numer­ous health, edu­ca­tion, and pro­duc­tiv­ity appli­ca­tions whose value and lim­i­ta­tions we are only start­ing to grasp.

Brain fit­ness has quickly become a main­stream aspi­ra­tion among baby boomers and elders, pri­mar­ily in North Amer­ica. It has fueled a grow­ing inter­est in brain fit­ness classes, brain fit­ness cen­ters, and brain fit­ness pro­grams, along with atten­dant oppor­tu­ni­ties and chal­lenges. An increas­ing num­ber of adults want use­ful tools to pro­tect cog­ni­tive health and performance—not nec­es­sar­ily to reverse aging—and what they are find­ing is an expand­ing and noisy mar­ket­place where they (and also pro­fes­sion­als) need to care­fully eval­u­ate their own needs and the avail­able options (Fer­nan­dez and Gold­berg, 2009). The recent dis­cov­ery that expe­ri­ence can change brain struc­ture and func­tion at any age has inspired a range of health, edu­ca­tion, and pro­duc­tiv­ity appli­ca­tions whose value and lim­i­ta­tions we are only start­ing to grasp. If you can envi­sion the array of equip­ment avail­able to train dif­fer­ent mus­cles in a typ­i­cal mod­ern health club, you can antic­i­pate the value—and per­haps the limitations—of hav­ing an expand­ing toolkit to mea­sure and enhance cog­ni­tion and men­tal well­ness. The bur­geon­ing brain fit­ness indus­try needs to define and refine itself, to mature, before it can be as estab­lished as today’s phys­i­cal fit­ness industry.

The good news is that adults of all ages are pay­ing more atten­tion to the impact of lifestyle options on cog­ni­tive health, and that there are more tools avail­able than ever before to assess, mon­i­tor, and enhance a vari­ety of cog­ni­tive, emo­tional, and self-regulation skills. The bad news is that there is no magic pill and that, as often hap­pens in emerg­ing markets,the over­whelm­ing amount of super­fi­cial media cov­er­age and hyped mar­ket­ing claims are pro­vok­ing con­sumer con­fu­sion and skep­ti­cism among researchers and professionals.

The Busi­ness of Brain Fitness

First, some per­spec­tive. I esti­mate that the size of the world­wide dig­i­tal brain fit­ness soft­ware mar­ket (defined as auto­mated appli­ca­tions that help assess, enhance, or repair tar­geted brain func­tions) in 2009 was $295 mil­lion, rep­re­sent­ing an annu­al­ized growth rate of 31 per­cent since 2005 (Fer­nan­dez, 2010). Around half of that amount, or $148 mil­lion, was spent by U.S.-based buyers.

Com­pare this to other fit­ness mar­ket seg­ments: in 2007, Amer­i­can con­sumers bought $3 bil­lion worth of tread­mills, and in 2009, Amer­i­can health club mem­ber­ships amounted to $19.5 bil­lion. Off-label drug pre­scrip­tion rev­enues in the United States alone exceed $10 bil­lion per year, and the cur­rent esti­mate for the North America’s vit­a­mins, min­er­als, and sup­ple­ments mar­ket is $17.7 billion.

The brain fit­ness soft­ware indus­try is only in its infancy; it is an emerg­ing and largely unreg­u­lated mar­ket where many prod­ucts have lim­ited clin­i­cal val­i­da­tion and often present con­fus­ing claims that make it dif­fi­cult for con­sumers to sep­a­rate wheat from chaff. If this is the case, can we expect this industry’s sig­nif­i­cant and con­tin­ued growth in the fore­see­able future?

Demand dri­ves supply

A grow­ing por­tion of the 78 mil­lion baby boomers in the United States is invest­ing time and effort into retain­ing their men­tal sharp­ness. This moti­vates health­care and insur­ance providers to intro­duce and test inno­v­a­tive solu­tions in areas such as dri­ving safety.

The often unrec­og­nized role of brain fit­ness soft­ware is that it can serve as both an assess­ment and an enhance­ment tool, and data­base dri­ven cog­ni­tive care solu­tions have started to become avail­able. At the same time, new community-based mod­els for pre­ven­tive ser­vices have begun to pop up to help cus­tomers put all the puz­zle pieces together and nav­i­gate the over­whelm­ing array of research, prod­ucts, and claims.

Sci­ence and research drive policy

There is accu­mu­lat­ing evi­dence that basic cog­ni­tive, emo­tional, and self-regulation brain based capac­i­ties are more mal­leable than once thought and that lifestyle, non-invasive interventions,and inva­sive inter­ven­tions can all play a role in aug­ment­ing or main­tain­ing cog­ni­tive and emo­tional health.

Major ini­tia­tives world­wide are start­ing to shift the over­all men­tal health dis­course from ill­ness and dis­ease to build­ing men­tal cap­i­tal and men­tal well-being through­out life.

The answer to the above ques­tion is a def­i­nite yes: brain fit­ness is here to stay. The next ques­tion is:  How do we har­ness this enthu­si­asm and energy to cre­ate and sup­port a sus­tain­able and valu­able field?

 The Ethics of Brain Fitness

The ter­mi­nol­ogy “fun­da­men­tal attri­bu­tion error” describes the ten­dency to over­value personality-based expla­na­tions for observed human behav­iors, while under­valu­ing sit­u­a­tional expla­na­tions for those behav­iors.  I believe that a pri­mary rea­son behind many per­ceived and real eth­i­cal chal­lenges in the brain fit­ness field is due not so much to cer­tain stake­hold­ers’ lack of per­sonal or pro­fes­sional ethics, but derives from the flawed soci­etal con­struct that under­pins cur­rent, rel­e­vant inno­va­tions. To improve the ethics of the brain fit­ness busi­ness and its appli­ca­tion (and empower con­sumers’ informed deci­sion mak­ing), there must first be agree­ment about a mean­ing­ful, appro­pri­ate way to ana­lyze and guide inno­va­tion. This is the crux of the prob­lem. The cur­rent med­ical model is not up to the task at hand, since it is heav­ily skewed toward inva­sive drugs and devices dri­ven by disease-based mod­els, and fails to lever­age cog­ni­tive reserve find­ings and the pro­tec­tive role of phys­i­cal exer­cise, cog­ni­tive engage­ment, and cog­ni­tive train­ing (Valen­zuela, 2009; AHRQ, 2010).

Surely there are other meth­ods bet­ter suited to the oppor­tu­nity at hand other than the purely entertainment-driven “brain age” inven­tion. The fol­low­ing quote from a recent paper in Global Pol­icy invites all stake­hold­ers to shift per­cep­tions of aging from bur­den to human cap­i­tal: “We con­tend that early and repeated pre­ven­tive care ‘inter­ven­tions’ (espe­cially in health behav­iors and geri­atric med­i­cine) and ‘pre­ven­tive’ mea­sures (such as social inte­gra­tion, design of cities and life­long learn­ing so that work­ers can upgrade skills) will delay the onset of late-life dif­fi­cul­ties” (Olshan­sky et al., 2011).

If we are to trans­form the con­ver­sa­tion that cur­rently focuses on the med­ical model of diag­no­sis and treat­ment of a col­lec­tion of dis­or­ders toward dia­logue that cen­ters upon a cost-benefits scal­able model of life-course invest­ments in brain health and fit­ness, what strate­gies could inform this new conversation?

Build­ing men­tal cap­i­tal and well-being

The Fore­sight Project on Men­tal Cap­i­tal and Well-being (The Gov­ern­ment Office for Sci­ence, 2008), a major research and pol­icy ini­tia­tive launched in 2008 by the gov­ern­ment of the United King­dom, was intended to “pro­mote opti­mal men­tal cap­i­tal tra­jec­to­ries through life for the gen­eral pop­u­la­tion [by] influ­enc­ing indi­vid­u­als’ men­tal devel­op­ment and well­be­ing from con­cep­tion until death, ana­lyz­ing pos­si­ble inter­ven­tions to address chal­lenges, draw­ing upon con­sid­er­a­tions such as sci­en­tific effi­cacy, eco­nom­ics, gov­er­nance and ethics.”

A grow­ing por­tion of the 78 mil­lion baby boomers in the United States is  invest­ing time and effort into retain­ing their men­tal sharpness.

The Project, a mas­sive endeavor mar­shal­ing hun­dreds of neu­ro­sci­en­tists, resulted in dozens of detailed reports and put for­ward a new frame­work to guide pub­lic pol­icy, with focus on the fol­low­ing two key concepts:

Men­tal cap­i­tal. “This encom­passes a person’s cog­ni­tive and emo­tional resources. It includes their cog­ni­tive abil­ity, how flex­i­ble and effi­cient they are at learn­ing, and their ‘emo­tional intel­li­gence,’ such as their social skills and resilience in the face of stress. It there­fore con­di­tions how well an indi­vid­ual is able to con­tribute effec­tively to soci­ety, and also to expe­ri­ence a high per­sonal qual­ity of life. The idea of ‘cap­i­tal’ nat­u­rally sparks asso­ci­a­tion with ideas of finan­cial cap­i­tal and it is both chal­leng­ing and nat­ural to think of the mind in this way.”

Men­tal well-being. “This is a dynamic state, in which the indi­vid­ual is able to develop their poten­tial, work pro­duc­tively and cre­atively, build strong and pos­i­tive rela­tion­ships with oth­ers, and con­tribute to their com­mu­nity. It is enhanced when an indi­vid­ual is able to ful­fill their per­sonal and social goals and achieve a sense of pur­pose in society.”

The Project issued a num­ber of life-course rec­om­men­da­tions, includ­ing the need to address the “mas­sive under-utilization of the men­tal cap­i­tal of older adults” and to “act deci­sively to estab­lish pro­tec­tive lifestyles for those in mid­dle age in areas where the sit­u­a­tion is set to worsen, such as the grow­ing num­ber of older peo­ple at risk of dementia.”

Ulti­mately, the pri­mary rec­om­men­da­tion culled from all the reports was to pro­mote opti­mal men­tal cap­i­tal tra­jec­to­ries through life for the gen­eral pop­u­la­tion since “…achiev­ing a small change in the aver­age level of well-being across the pop­u­la­tion would pro­duce a large decrease in the per­cent­age with men­tal dis­or­der, and also in the per­cent­age who have sub-clinical disorder.”

Trans­lat­ing this to prac­tice, the U.K.’s National Health Ser­vice has started to adopt a care model that relies heav­ily on self-care and auto­mated ser­vice mod­els early on in the care con­tin­uum. Com­put­er­ized Cog­ni­tive Behav­ioral Ther­apy (CBT) has become the first stan­dard of care for patients pre­sent­ing with mild or mod­er­ate depres­sion, rather than imme­di­ately opt­ing for anti­de­pres­sant med­ica­tion. Given the mis­match between the num­ber of avail­able, trained ther­a­pists and peo­ple who would ben­e­fit from this form of brain train­ing, computer-assisted CBT can make a sig­nif­i­cant dif­fer­ence as a com­ple­ment or alter­na­tive to therapist-delivered CBT.

 

Engag­ing peo­ple where they are in the life-course

Eighty per­cent of the 38,000 adults over age 50 who were respon­ders in the 2010 AARP Mem­ber Opin­ion Sur­vey indi­cated “stay­ing men­tally sharp” was their top ranked inter­est and con­cern (Dinger, 2010). What exactly does this phrase mean? And what role can tech­nol­ogy play in “stay­ing men­tally sharp”? Intel CEO Paul Otellini has said, “You have to start by think­ing about what peo­ple want to do… and work backward.”

The grow­ing inter­est in brain fit­ness presents a sig­nif­i­cant oppor­tu­nity to build men­tal cap­i­tal, enhance men­tal well­ness, and delay symp­toms of brain-based decline and disease.

In March 2008, AARP ran their Healthy@Home Sur­vey (Bar­ret, 2008) ask­ing just under 1,000 respon­ders, ages 65 and over (mean age of 74 years), and their care­givers about their per­cep­tions of suc­cess­ful aging and tech­nolo­gies for suc­cess­ful aging. In a nut­shell, the survey’s main find­ings were that older adults pri­or­i­tize health and inde­pen­dence, that their obsta­cles have a strong cog­ni­tive or per­cep­tual com­po­nent, and that they are open to dig­i­tal health technology.

In other words, the top pri­or­ity for older adults is not anti-aging—it is about main­tain­ing capac­i­ties to func­tion inde­pen­dently. This is where recent cog­ni­tive sci­ence and dig­i­tal tools can add more value: man­ag­ing and enhanc­ing “brain fit­ness” in the present and the near future—not just pre­vent­ing or treat­ing Alzheimer’s Dis­ease thirty years from now.

What are some of the areas where peo­ple want more help with brain fit­ness? To answer this ques­tion, Sharp­Brains (www.sharpbrains.com) con­ducted a sur­vey in March 2010 of our monthly newslet­ter sub­scribers (a group not rep­re­sen­ta­tive of the pop­u­la­tion at large, but indica­tive of early adopters and deci­sion mak­ers). We received nearly 1,700 responses from respon­dents who were ages 40 and older.

When asked what were the most impor­tant brain func­tions nec­es­sary to thrive per­son­ally and pro­fes­sion­ally in the twenty-first cen­tury, respon­dents’ pri­or­i­ties cov­ered a range of cog­ni­tive, emo­tional, and self-regulation func­tions, sug­gest­ing that brain fit­ness solu­tions will need to inte­grate all these domains—or at least be able to link their spe­cific func­tional ben­e­fits to spe­cific user pri­or­i­ties. It was inter­est­ing to con­trast the top two ranked func­tions (“abil­ity to man­age stress­ful sit­u­a­tions”; “con­cen­tra­tion power to avoid dis­trac­tions”) with the bot­tom two (“abil­ity to mul­ti­task”; remem­ber­ing faces and names”), which may debunk many myths about our assump­tions of what peo­ple actu­ally want and need. When asked for their beliefs about the effec­tive­ness of cer­tain habits and tools, respon­dents named intel­lec­tual chal­lenges, aer­o­bic exer­cise, and read­ing books as most effec­tive, closely fol­lowed by meditation.

Sim­ply stated: what peo­ple seem to want is help to enhance and pro­long their func­tional men­tal capac­ity. The next step is to deter­mine how older adults can best nav­i­gate through the brain fit­ness marketplace.

Empow­er­ing Pro­fes­sion­als to Empower Consumers

Insti­tu­tions and pro­fes­sion­als in the field of aging have the daily task of help­ing con­sumers, patients, and care­givers nav­i­gate the avail­able non-invasive options. Per­son­al­ized assess­ments and advice are crit­i­cal, since improve­ments expe­ri­enced in ther­apy and train­ing pro­grams seem more likely to trans­fer to real life when a per­son tar­gets the brain function(s) that are specif­i­cally rel­e­vant to their unique con­text and its bot­tle­necks or deficits (Sharp­Brains, 2011).

Peo­ple have dif­fer­ent needs and pri­or­i­ties, have vary­ing lifestyles, and reside in par­tic­u­lar cog­ni­tive envi­ron­ments: one size does not fit all.

I pro­pose that insti­tu­tions and pro­fes­sion­als who must tra­verse this still-emerging, com­plex land­scape first iden­tify an individual’s par­tic­u­lar bot­tle­necks or deficits, then seek the level of clin­i­cal val­i­da­tion for options (technology-based or not) that tar­get those spe­cific cog­ni­tive, emo­tional, or self-regulation func­tions. (See the list on page 68 that can help pro­fes­sion­als eval­u­ate brain fit­ness options.)

The other role pro­fes­sion­als play is in edu­cat­ing and empow­er­ing con­sumers, patients, and care­givers to enhance their self-efficacy by mak­ing their own deci­sions. (Our Sharp­Brains 2009 con­sumer guide included a pro­gram eval­u­a­tion check­list, excerpted in the box on this page; the full check­list is avail­able at www.SharpBrains.com.)

In the absence of per­fect answers—and we won’t have per­fect answers for a while, if ever—today’s best course is to pro­vide edu­ca­tion and resources that facil­i­tate informed deci­sion mak­ing. Pro­fes­sion­als in the field of aging are in a unique posi­tion to help parse the offer­ings in the rapidly evolv­ing field of brain fitness.

How to Eval­u­ate Brain Fit­ness Pro­grams: A Con­sumer Checklist

Are there sci­en­tists and neu­ropsy­chol­o­gists, and a sci­en­tific advi­sory board behind the program?

  • Are there pub­lished, peer-reviewed sci­en­tific papers in main­stream sci­en­tific and pro­fes­sional jour­nals writ­ten by those sci­en­tists? How many?
  • Does the pro­gram tell me what part of my brain or which cog­ni­tive skill I am exercising?
  • Is there an inde­pen­dent assess­ment tool to mea­sure my progress?
  • Is it a struc­tured pro­gram, with guid­ance on how many hours per week and days per week to use it?
  • Do the exer­cises vary and teach me some­thing new?
  • Does the pro­gram chal­lenge and moti­vate me, or does it feel like it would become easy once I learned it?
  • Does the pro­gram fit my per­sonal goals?
  • Does the pro­gram fit my lifestyle?
  • Am I ready and will­ing to do the pro­gram, or would it be too stressful?

 —

Build­ing Blocks for a Bet­ter Future

The best alter­na­tive for tomor­row should be bet­ter than the best alter­na­tive avail­able today. How do we get there, when “cog­ni­tion” and “brain fit­ness” remain elu­sive con­cepts in pop­u­lar cul­ture? I believe that the lack of pub­lic edu­ca­tion is the major obsta­cle that lim­its the brain fit­ness field’s poten­tial to deliver real-world ben­e­fits, since only informed demand will ensure the ongo­ing devel­op­ment of ratio­nal, struc­tured “rules of the road.” What could be done to address this and other par­tic­u­lar obstacles?

Edu­cate the pub­lic
Ramp up efforts to build pub­lic aware­ness around a cul­ture of brain fit­ness and men­tal cap­i­tal across the lifes­pan, includ­ing estab­lish­ing clear links to daily life and work and the role of cog­ni­tive, emo­tional, and self-regulation fac­tors. Too many peo­ple still view men­tal capac­ity as a kind of uni­fied trait (such as IQ) that is deter­mined by our genes and can only decline with age.

Make it eas­ier to nav­i­gate claims
Easy-to-understand and research-based tax­onomies could help con­sumers and pro­fes­sion­als eval­u­ate prod­uct claims. Per­haps a label­ing sys­tem, sim­i­lar to the Good House­keep­ing Seal of Approval, will emerge at the ini­tia­tive of a reg­u­la­tor or of the industry.

Offer objec­tive cog­ni­tive assess­ment tools
It has been said that “you can’t man­age what you can’t mea­sure.” Reli­able, objec­tive assess­ment tools are crit­i­cal. Ide­ally, assess­ments would be adapted to the par­tic­u­lar cog­ni­tive demands of dif­fer­ent pri­or­i­ties and set­tings such as work­place per­for­mance, func­tional aging, dri­ving, work­ing as a pilot, or clin­i­cal con­di­tions. Per­haps the sin­gle most effec­tive way to bring cog­ni­tive research into the main­stream con­ver­sa­tion would be if peo­ple took an “annual brain check-up” (ASA-MetLife Foun­da­tion, 2006) to under­stand their own oppor­tu­ni­ties for improve­ment and progress, and to sup­port clin­i­cal deci­sion making.

Empha­size brain fit­ness at the pro­fes­sional level
Pro­fes­sional asso­ci­a­tions could beef up their efforts to add a brain fit­ness lens to their exist­ing offer­ings; this could help incor­po­rate an empha­sis on cog­ni­tion, neu­ro­plas­tic­ity, and men­tal well­ness into main­stream activities.

Advo­cate for more and bet­ter research
There are two main pri­or­i­ties for research: to develop widely accepted out­come stan­dards, includ­ing an estab­lished set of “func­tional mark­ers” at dif­fer­ent lev­els (such as brain-based, cog­ni­tive, and behavioral-functional) for dif­fer­ent pop­u­la­tions; and to fund tri­als that test mul­ti­modal inter­ven­tions. Iden­ti­fy­ing the respec­tive and com­ple­men­tary ben­e­fits of dif­fer­ent types of inter­ven­tions can result in bet­ter inte­grated and per­son­al­ized prod­ucts and programs.

Nav­i­gat­ing the Cog­ni­tive Prod­uct Maze: Ten Things to Consider

  1. Tar­get Users. What cohort of the pop­u­la­tion you serve is ready and will­ing to use these pro­grams? What cri­te­ria are most impor­tant to that group?
  2. Tar­geted Ben­e­fits. What are the spe­cific cog­ni­tive, emo­tional, or self-regulation skills that the pro­gram aims to enhance or retrain? What is the fre­quency of use (how many hours per week or num­ber of weeks)?
  3. Appro­pri­ate Level of Chal­lenge. Do the exer­cises adjust to the individual’s skill level and con­tin­u­ally vary and chal­lenge users at an appro­pri­ate pace?
  4. Sci­en­tific Cre­den­tials. Are there sci­en­tists (ide­ally, neu­ropsy­chol­o­gists) behind the pro­gram? Is there a clearly defined and cred­i­ble sci­en­tific advi­sory board? Are there pub­lished, peer-reviewed sci­en­tific papers on the program’s efficacy?
  5. Return on Invest­ment. What are your organization’s key busi­ness objec­tives, and can you inde­pen­dently mea­sure pro­gram results to eval­u­ate whether or not the pro­gram will meet those objectives?
  6. Total Cost of Own­er­ship. What will the total cost of own­er­ship be over the next three to five years includ­ing up-front fees, ongo­ing fees, hard­ware, soft­ware, train­ing and sup­port fees, cost of addi­tional mod­ules, and staff time? How many users will likely end up using the prod­uct or sys­tem, and what would be the cost of own­er­ship per user?
  7. Tech­ni­cal Require­ments. What are the tech­ni­cal require­ments needed to suc­cess­fully deploy and main­tain the pro­gram? Does it require Inter­net access? Are peo­ple expected to install their own CD-ROMs? Who will help solve poten­tial tech­ni­cal main­te­nance glitches?
  8. Staff Train­ing. What type of train­ing is required to run the pro­gram and who will pro­vide it?
  9. Prod­uct Roadmap. What is the vendor’s prod­uct roadmap? What is the ven­dor devel­op­ing and plan­ning to offer over the next one to three years?
  10. Ref­er­ences. What sim­i­lar providers have used this spe­cific pro­gram? What ben­e­fits have they mea­sured directly? Is the use of the pro­gram grow­ing, or is it flat or declining?

Sum­mary: Work Toward Accord

The grow­ing inter­est in the sci­ence, prac­tice, and busi­ness of brain fit­ness presents a sig­nif­i­cant oppor­tu­nity to build men­tal cap­i­tal, enhance men­tal well­ness, and delay symp­toms of brain-based decline and dis­ease. To best cap­i­tal­ize on this oppor­tu­nity, stake­hold­ers must agree on a mean­ing­ful and appro­pri­ate capacity-based framework—one that sup­ports both con­sumers and pro­fes­sion­als in mak­ing informed deci­sions, and that allows for person-centered and cross sec­tor inno­va­tion. Such accord can mean that in five to ten years, we may find our­selves in a much bet­ter place. Where to start? By devel­op­ing a cul­ture of brain fit­ness and men­tal cap­i­tal that spans from cra­dle to grave: I pro­pose that this is the real business—and guid­ing ethic—of the brain fit­ness field.

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Alvaro Fer­nan­dez, M.B.A., M.A., is CEO of SharpBrains.com.

Copy­right © 2011 Amer­i­can Soci­ety on Aging; all rights reserved. This arti­cle may not be dupli­cated, reprinted or dis­trib­uted in any form with­out writ­ten per­mis­sion from the pub­lisher: Amer­i­can Soci­ety on Aging, 71 Steven­son St., Suite 1450, San Francisco,CA 94105–2938; e-mail: info@asaging.org.

Credit for pics: Big­Stock­Photo.

 

Ref­er­ences

Agency for Health­care Research and Qual­ity (AHRQ). 2010. Alzheimer’s Dis­ease and Cog­ni­tive Decline, Struc­tured Abstract.April 2010. Agency for Health­care Research and Qual­ity, Rockville, Md.www.ahrq.gov/clinic/tp/alzcogtp.htm. Retrieved April 11,2010.

ASA-MetLife Foun­da­tion. 2006.Attitudes and Aware­ness of Brain Health Poll. San Fran­cisco, Calif.: Amer­i­can Soci­ety on Aging.

Bar­ret, L. 2008. Healthy@Home Sur­vey (research com­mis­sioned and funded by Blue Shield of Cal­i­for­nia Foun­da­tion to AARP Foun­da­tion). Wash­ing­ton, D.C.: AARP Foundation.

Dinger, E. 2010. Lis­ten­ing to the Mem­ber: The 2010 AARP Mem­ber Opin­ion Sur­vey. AARP Research & Strate­gic Analy­sis. Washington,D.C.: AARP.

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