As reported by Healthcare Ledger, March 9, 2010.

Cognitive Fitness

By Sandra Dias

The old adage "use it or lose it" certainly applies to muscle strength, stamina, and overall physical wellbeing. Research now shows it also applies to brain function.

Geriatric specialists say the more you exercise the brain with new, complex and stimulating activities, the healthier your brain will be—better able to stave off memory problems and dementia. Maintaining cognitive fitness as you age may even provide some protection against degenerative diseases such as Alzheimer’s.

"There is a lot of evidence that keeping one’s mind active later in life, even once cognitive deficiency has begun, appears to be very beneficial," said George Kuchel, M.D., professor of medicine at the University of Connecticut School of Medicine and director of the UConn Center on Aging. “Interestingly, we are also seeing that physical activity not only helps to prevent physical decline, it also helps to preserve cognitive functioning."

"Some amount of cognitive decline is a normal part of aging," Kuchel said. Scientific research shows that certain parts of the brain actually shrink with age. As a result, critical metabolic processes are disrupted and nerve cells in the brain stop working, lose connections with other nerve cells, and ultimately die, leading to memory failure, personality changes, and problems conducting basic activities of daily life. Parts of the brain most affected are the prefrontal cortex and the hippocampus. Both areas are important to learning, memory, and planning, according to the National Institute on Aging.

In addition, the brain also begins to store abnormal substances such as amyloid plaques and neurofibrillary tangles which are featured characteristics of Alzheimer’s.

In 1989, researchers conducting a post-mortem analysis of 137 people with Alzheimer’s discovered that some patients demonstrated fewer clinical symptoms than expected, given the amount of plaques and tangles in their brains. These patients had higher brain weights and greater numbers of neurons. Researchers postulated that the patients had a larger “reserve” of brain neurons and abilities that allowed them to off set the losses caused by Alzheimer’s. The research led to the development of cognitive reserve theory, which asserts that if enough healthy brain cells and brain cell connections remain, people can escape symptoms like memory loss and the disorganized thinking that characterize Alzheimer’s.

One of the greatest boosters of cognitive reserve is lifetime education, Kuchel said. Intellectual stimulation throughout life is now believed to build brain cells and improve connections between them. It appears that education acts as a buffer against normal cognitive declines associated with aging, as well as pathological changes. Kuchel said there is substantial evidence that higher education offers "major" protection against the development of dementia. But whether one has a Ph.D. or merely a high school education, it is never too late to challenge the brain; in fact, it is critical. The key is to learn how to slow stages of cognitive decline when the signs are still minimal. Kuchel said there are two ways to preserve mental function early on: maintain a healthy lifestyle and perform brain workouts.

"Dementia does not just affect people with Alzheimer’s," Kuchel said. "People with diabetes, hardening of the arteries, and multiple strokes are at greater risk of developing dementia. Anything you can do to prevent those diseases—keeping your weight down, eating a healthy diet, getting good treatment for high blood pressure, avoiding smoking and heavy drinking—all can help prevent dementia as we age."

Sweat is not a prerequisite. "It doesn’t even have to be particularly vigorous exercise," Kuchel said. "Simply taking a walk for two blocks each day is very beneficial." In order to train the brain to fight dementia, Kuchel recommends any activity that requires one "to retain information and retrieve it." Old-fashion crossword puzzles are good brain boosters as are ballroom dancing, studying a foreign language, riddles, trivia and math. Brian K. Dessureau, Ph.D., a clinical neuropsychologist and assistant professor at UMass Memorial Health Care in Worcester, MA, said it is important for people to "continue to explore their areas of interest...it has less to do with a specific activity and more to do with finding things that keep the older person engaged and challenged," especially after retirement. When someone retires or loses a spouse, Dessureau said there is a "risk of losing an established way of remaining active" in life.

But just finding something to keep busy is not good enough. It’s important for any cognitive activity to challenge the participant, said Patti Celori Said, B.A., M.A., executive director of the New England Cognitive Center (NECC), a non-profit organization that develops and disseminates innovative research-based cognitive fitness programs in Hartford, CT. Someone who does a lot of crossword puzzles may enjoy them and be good at them, for instance, but they may not sufficiently stimulate the brain if they are not hard enough.

"It’s just like when you are at the gym, ‘no pain, no gain,’" she said. "You have to be working at something and feel those cognitive wheels turning. If it’s too easy, you are not going to get that cognitive workout...or that brain burn." Both Kuchel and Dessureau said they have seen a sharp increase in the number of older patients ask about dementia and ways to improve the mind’s agility. The rise in interest is, in part, due to increased awareness about Alzheimer’s and the burden older adults are feeling as caregivers to their parents. The number of inquiring minds will increase over time as the first wave of Baby Boomers turn 65 next year and become eligible for Medicare. Seventy-six million Americans were born at the height of the Baby Boom, and they became the healthiest, wealthiest, most educated citizens in the country’s history.

"The Baby Boomers are very concerned about how they are going to age," Kuchel said. Sales of all kinds of products to reduce the effects of aging—from plastic surgery to anti-aging creams to vitamin supplements— are on the rise. Interest also is high in computerized "brain fitness" programs to help ward off dementia. Home-computer brain fitness software jumped from $100 million in revenues in 2005 to $225 million in 2007.

By 2015, they are expected to reach $2 billion, according to SharpBrains, a company that tracks the cognitive fitness market. Deficiencies in vitamins, such as B12, certainly can contribute to memory problems, as can thyroid disorders. But high-dose vitamins in the absence of a deficiency appear to have no added benefit when it comes to boosting brain power; excessive vitamin intake can actually be detrimental to one’s health. New research shows that fish oil in very high amounts may help stave off cognitive decline.

The rush against time to find solutions is personal. According to the American Geriatrics Society, an estimated four million Americans are diagnosed with Alzheimer’s. Researchers anticipate that number will grow exponentially in the years ahead. Baby Boomers who are caring for parents suffering from the disease don’t want to be part of that statistic. “My own mom has dementia and we want to do what we can to prevent ourselves and our kids from going through that, ”said Janie Clark, M.A., president of the American Senior Fitness Association (SFA).

The SFA recently developed a new brain fitness training program designed for exercise professionals. Brain Fitness for Older Adults teaches senior fitness instructors and personal trainers how to incorporate cognitive fitness into exercise programs, offering seniors the opportunity to boost both physical and mental fitness simultaneously.

The programs are a big hit in retirement communities. The Village at McLean in Simsbury, CT, purchased the (m)Power Cognitive Fitness Program from Dakim, a California-based creator and developer of brain games currently used by more than 300 senior living communities in 34 states. After using it for almost two years, the Village was so pleased with results, it purchased three more. Dakim’s brain fitness system, priced at $2,299 plus $20 per month, offers more than 150 different types of brain games at 5 different levels of challenge. Two years ago, Dakim signed fitness pioneer Jack LaLanne, 95, to be a "brain fitness motivational coach."

Power provides brain-building activities for senior citizens on a touch screen computer device that requires no mouse, keyboard, computer knowledge or software loading. Activities are presented in a game show-like format and are updated every few days. The system self-adjusts to meet the ability of the person playing, with activities geared towards healthy seniors all the way to early-stage Alzheimer’s patients. The program builds a profile on each user, based upon age, educational level, and interests, and shapes its content to address those interests. Each 20- to 30-minute session exercises short- as well as long-term memory, critical thinking, visual-spatial ability, calculation and language for a thorough brain workout.

Activities range from anagrams and name that- tune challenges to interactive puzzles and narrated literary passages with follow up questions. Colorful screen images, stories, voiceovers, pre-1950s film and music clips that tap into seniors’ memory banks, and a constant supply of new exercises keep users engaged and encourage sustained use.

In one, called Keep Your Eyes Open, players watch scenes from old movies, and then are asked to recall details such as the characters’ names and what they said. The Violin game plays recordings of famous classical musicians, and even a scene from The Jack Benny 1950s TV show, to engage in a tutorial on the string instrument. "If I am a 45-year-old woman who is interested in quilting, it will ask me questions based on the creative arts," said Village Director Megan Gill. “I might get a math question related to how many pins it would take to put together a quilt, while a 90-year-old guy interested in football would get a question about an Army-Navy game and how many points they would need to get in the 4th quarter with two downs to go." Gill was fascinated to see a client in the facility’s long-term care unit who was unable to communicate verbally due to multiple strokes use Dakim. He used the (m)Power and "did quite well...Through that and other forms of communication, he was able to let us know that mentally, he is still in there."

A couple months ago, Lifespace Communities, the nation’s 7th largest not for profit independent living provider, announced that it was partnering with Dakim to provide the system for its 4,500 residents in 11 communities across the U.S. "Choosing an engaging brain fitness program to help residents fight the threat of memory loss is yet another compelling advantage our residents have access to in our communities," said Scott Harrison, president/ CEO of Lifespace Communities.

"The 50s marked the beginning of our understanding of physical health and muscle conditioning...We are now learning more and more about the brain and what happens to the brain as we age," said Said. "Right now, we know we can make a difference in cognitive abilities by putting our brains through different exercises and strengthening different areas."

A Workout for Your Brain

Interest Is Booming in Ways to Boost Brainpower as We Age

The American Senior Fitness Association recently launched a brain fitness program that teaches exercise trainers how to incorporate cognitive fitness into physical fitness programs at senior centers and retirement communities. Approved for 2.0 Continuing Education Units (20 hours credit) by the American Council on Exercise, Brain Fitness for Older Adults is available for $249.00. Upon successful completion of the program, including a 190 multiple choice test questions designed to evaluate mastery of the program’s learning objectives, trainers earn their professional certificate as an American Senior Fitness Association Cognitive Fitness Facilitator. "This ties in with the other health promotion work that senior fitness professionals are already doing," said Janie Clark, M.A., president of the American Senior Fitness Association. "We teach them how to help older adults to stay bright and alert and the program is geared towards people who are already coming in for physical fitness classes."

The 20-25 hour educational program teaches exercise professionals, recreational therapists, and others who work with senior citizens about the basic anatomy of the brain and cognitive areas that are affected with aging. The trainers learn how to talk to seniors in exercise classes about things they can do to boost brain power, such as crossword puzzles, cryptograms, and brainteasers. They are also asked to encourage seniors to find pursuits that are personally meaningful. Exercise professionals also learn how to guide aging seniors to maintain social activities, relationships with neighbors, and community work. Other features of the program include lessons on healthy eating, the incorporation of a social hour after fitness class, and stress management, all of which can help to boost cognitive fitness. "There is a connection between stress and depression and the state of one’s cognitive health," Clark said. "We teach the instructors and trainers how to integrate stress management and relaxation techniques into their classes."

The new program is more of a lifestyle approach to cognitive wellness. NECC originally developed its non-computer based Brain G.Y.M.M. (Get Your Mind Moving) programs to maximize the capabilities of people with early stage Alzheimer’s or mild cognitive impairment. Based on resident feedback, staffers discovered the programs were also beneficial to a wide range of older adults, including those who are aging "normally" to those with brain injury, stroke and vascular disorders. NECC trains staff members at community agencies, such as senior centers, adult day centers and assisted living residences, to deliver mind aerobics. The one-day Train-the- Trainer package licenses two or more on-site staff members. NECC provides a trainer’s guide and program-specific sourcebook with curriculum, reusable activity directions and answer keys. The Apprentice Program in which staff members deliver classes alongside an NECC trainer is also available. The five 8-to-12 week classes offered to range in challenge levels from Active Mind, a workshop for moderately severe cognitive decline to Mind Sharpener for normal to forgetful seniors. The classes do not use computers.