Preventing Dementia and Cognitive Decline

Lane Therrell FNP, MSN, RN, NP

Recent health-news headlines identified three potentially effective interventions for preventing dementia and cognitive decline: blood pressure control, physical activity, and cognitive training. The interventions were featured in a National Academies of Sciences Engineering and Medicine (NASEM) report released June 22, 2017. The press release which announced the June 2017 NASEM report stopped short of making definitive health claims or calling for official promotion of these interventions, and instead emphasized that the NASEM report represented a call for further research.

While researchers build the official evidence base for preventing dementia and cognitive decline, nurses at all levels of practice can continue to provide commonsense patient education on these interventions and others like them, in the name of quality care. This article reveals some of the ways I have successfully integrated the idea of potentially preventing dementia and cognitive decline into patient education on blood pressure management, physical activity, and cognitive training.

Blood Pressure Management

Dementia prevention research increasingly shows that managing hypertension optimally, especially during midlife, sets the stage for a healthier brain in later life. This can be a useful concept for patients to understand as they integrate the multiple lifestyle changes (including exercising regularly, limiting sodium, caffeine and refined sugar, managing stress, mastering relaxation, and stopping smoking) that will help them manage their blood pressure.

As a family nurse practitioner in primary care, I know first-hand how challenging it can be to help my otherwise healthy mid-life patients with hypertension understand the importance of adhering to their plans of care for controlling blood pressure. "I feel fine," "It doesn't really affect me," and "I can't remember to take that pill every day," are just some of the many excuses I hear repeatedly.

When patients' blood pressure numbers do not coincide with urgent symptoms it can be difficult for them to understand why they need to take corrective action. Berating the patient for not taking their pills or convincing them to make changes in long-standing habits or routines when they have no immediate incentive to do so [is not easy] will not be effective unless the patient is invested in doing so.

One useful technique involves having a meaningful conversation in three parts. The first step is to ask the patient about their experiences with family or loved ones who suffer from dementia or cognitive decline. The next step is to help them connect the dots between their current state of health and what that could potentially lead to in their own future. Conclude the conversation by helping the patient create an ideal vision of what their own aging process might look like. This can set the stage for lifestyle changes that will. Patients that have engaged in these types of conversations with me have been able to own their lifestyle changes in sustainable ways.

Physical Activity

Epidemiological studies demonstrate that physically active individuals are less likely than inactive individuals to develop Alzheimer's disease. Not only does regular physical activity support blood pressure management, it also may prevent dementia and cognitive decline as a stand-alone intervention. But the research in humans and animals is not yet conclusive. This is why researchers are very careful to emphasize that their findings could be due to any combination of healthy habits, not exercise alone.

Animal studies are the first step in the research process, and the results so far are promising. So far, animal studies designed to investigate the effects of exercise on brain health show that exercise increases the number of small blood vessels as well as the connections between nerve cells and the production of nerve growth factor in the brains of older mice. Findings like these add to the body of research in other areas which support the notion that the benefits of physical exercise likely extend far beyond physiology, as exercise is well known to be accompanied by improved neurotransmitter production and the accompanying psychological benefits as well. It will be interesting to see what the research concludes in the future. Time and future studies will tell us more.

Research like this supports the rationale I like to offer my patients for making comprehensive healthy lifestyle changes-that consistent physical exercise represents an investment in your ongoing overall best health. When working with patients who are resistant to the idea of incorporating regular exercise into their daily lives, or who offer excuses such as, "I don't have time" or "I don't like to sweat," I always find it useful to emphasize the links between physical exercise, brain health, and the patient's own visualization of ideal aging (see three-part conversation as outlined above). I find it is effective to support my patients' efforts to engage in regular physical exercise by encouraging them to reconnect with activities they have always enjoyed in addition to exploring new and different physical activities that extend beyond their current daily routines. Sometimes all a patient needs is permission to play more often.

Cognitive Training

Neuroplasticity* is the idea that the brain is constantly changing, and is even capable of a certain level of regeneration, not just in early childhood but throughout the lifespan. In response promising research results investigating neuroplasticity in the growing field of neuroscience, numerous online cognitive training programs, popularly known as "brain training," have become available in recent years.

While the body of evidence is still developing about the extent to which cognitive training exercises may actually prevent age-related cognitive decline, online brain training has exploded into a billion-dollar business. As such, it can be difficult for consumers to separate scientifically based information from marketing hype. While it can be a daunting task for a non-specialist nurse to commit to staying abreast of all the latest research findings in neuroscience, we can still choose to steer our patients in a healthy direction by adopting a balanced approach to cognitive training.

For example, the concept of balance influences my patient education whenever I encourage my patients to keep their brains active by participating in a wide variety of things that interest them. I encourage activities that integrate multiple senses and require immersion in a richly stimulating environment (examples include hiking, dancing, gardening, crafting, etc.). If online brain games intrigue your patients, and they have the resources to participate, they should definitely explore them. But in the name of balance, nurses should also discuss the value of establishing prudent limits on digital screen time, and integrating multi-sensory non-digital** activities, since screen-based activities tend to emphasize certain brain functions over others.

If you are working with a patient who enjoys digital technology and is interested in online brain training programs, or if you are a nurse who is integrating cognitive training into your patients' plans of care, common sense indicates that balance is always a good foundation to build upon. It may be helpful to remember that "digital dementia" is a term coined by German neuroscientist Manfred Spitzer in 2012 to describe the consequences of the overuse of digital technology. Think about it-- we're no longer using our brains to recall phone numbers for friends and family because our smartphones do it for us, and our neuroplastic brains can't help but change as a result.

In summary, dementia and cognitive decline are complex conditions with numerous contributing factors and dire consequences, so it's no surprise that any hint of prevention or mitigation will be widely discussed and popularized. While researchers continue to build the evidence base, responsible nurses who are committed to delivering the highest standard of care can continue to encourage balance and adherence in their patients' plans for blood pressure management, regular physical exercise, and varying forms of cognitive stimulation.

*For anyone interested in learning more about the topic of neuroplasticity, two great books to read are "The Brain That Changes Itself" (2007) and "The Brain's Way of Healing" (2016), by Norman Doidge.

**If the big picture of how to engage the brain non-digitally interests you, a fabulous book that lists numerous practical suggestions that are easily adaptable for adults of middle age and beyond is: "Keep your Brain Alive" (1999, 2014) by Lawrence Katz.

Questions for Discussion

What are your thoughts on preventing cognitive decline? Have you or your patients used online cognitive training programs? What is your favorite method of multi-sensory brain stimulation?