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Alzheimer’s Disease Prevention or Cognitive Enhancement?

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:

    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. 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. 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. 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:

    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. 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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