Brain experts already know that a number of habits can keep the brain in good shape. Exercise, a healthy diet, staying socially engaged, getting enough sleep, and maintaining heart health can all help slow cognitive decline.
But most of that understanding comes from observational studies, which correlate people’s behaviors with outcomes while trying to account for other factors that may interfere with the results. While useful, these do not yield the type of solid scientific evidence that doctors like to act on and strongly recommend to their patients.
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A new study published in JAMA and presented at the Alzheimer’s Association International Conference, however, may finally provide the stronger evidence that doctors pass on to their patients.
The study included more than 2,100 older adults—ages 60 to 79—who did not have symptoms of cognitive decline or dementia but who were at higher risk for them. Their risk factors included being sedentary, eating an unhealthy diet, having a family history of memory problems or a genetic predisposition for them, having heart disease risk factors, or belonging to certain ethnic groups that have a higher risk of developing dementia and Alzheimer’s disease.
The two groups were randomly assigned to one of two lifestyle programs that ran for two years. One was more structured and involved 38 group sessions in which clinicians and participants set goals for meeting certain health benchmarks. It also included weekly online brain- training sessions, appointments to review lab test results with a clinician, and a $10 monthly rebate, provided by the U.S. Highbush Blueberry Council, for people to purchase blueberries. (Studies have linked the antioxidants in blueberries to slower cognitive decline.) The other less-structured group was provided general information about making brain-healthy changes, met in teams about three times a year, and was provided a $75 gift card at each meeting to spend as they wished on healthy behavior changes.
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Phyllis Jones, from Aurora, Ill., had a personal reason for joining the study. “I watched my mom with dementia for 8.5 years,” she says. “It was very difficult to watch. But what made it harder for me was that I had seen my mother caring for her mother. So I saw two generations ahead of me go through that.” Joining the study, she says, “gave me a way to try to break the cycle from happening again.”
At the end of the study, everyone improved on their cognitive function score, but the group following the more structured program showed significantly greater improvement. On average, those in the structured change group appeared to slow their cognitive decline by one to two years.
“Because of the rigor of the trial, the size of the trial, and the care we took in rolling out the interventions, we now finally have scientific evidence that healthy behavior does matter,” says Laura Baker, professor of gerontology and geriatrics at Wake Forest University School of Medicine. “That’s new information. We all think we know it, but until now, we didn’t have the science.”
Jones, who was part of the structured group, says that prior to the study, she was stressed out at work and not taking care of her health. “I was not exercising or eating the right things,” she says. The turning point for her, she says, occurred when her son said, “‘Mom, I didn’t expect to be a caregiver for you at this stage in your life, not yet.’ I knew I had to find a way out of this dark hole.”
While the structured program required more commitment and accountability from the participants, Jones says she didn’t feel discouraged or frustrated with making the changes, since the study ramped them up gradually, and she had the support of other people in her group. “We had team meetings, and instead of starting out with the prescribed 30 to 35 minutes of exercise a day, four times a week, we started with 10 minutes a day and moved up from there,” she says. “If you are living a sedentary lifestyle, 10 minutes a day is a good start. And then if you can get through the 10 minutes, you can push to 20 minutes and then get to 30 minutes.”
One of the women in Jones’ group was Patty Kelly, and the two inspired and motivated each other. Kelly, 81, says she struggled with weight most of her life, and weighed 130 pounds in the third grade. Like Jones, her mother was diagnosed with dementia at 77, and Kelly cared for her for seven years, watching as her mother gradually failed to recognize her family. “I wanted to make sure my sons did not have to go through that with me,” she says.
Both Jones and Kelly say they are different from when they began the study in many ways. Kelly says her driving has improved, which she attributes to the regular brain-training exercises she did on the computer as part of the study. “At this point, I’m living my life with my arms wide open,” says Jones, who is now working at a job she loves. “I’m just having a ball.”
The improvement occurred in people with the APOE4 genetic risk factor for Alzheimer’s disease, as well as those without the mutation—an encouraging indication of the power of lifestyle changes.
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Everyone experiences cognitive decline with age, Baker says. But the results provide reassuring evidence that not all cognitive decline that occurs with age is inevitable. The trial was a continuation of a similar study published in 2015 from Finland demonstrating similar cognitive benefits in people at risk of developing Alzheimer’s and other dementias who made behavior changes. The current trial was intended to involve a more diverse population at risk of not just Alzheimer’s, but the broader condition of dementia. “It doesn’t reverse the clock but it’s very clear that it can slow, and pull back the clock by one to two years,” she says.
Baker and her colleagues determined this by relying on a global score to measure people’s cognitive state—the result of a compilation of different cognitive tests that neuropsychologists typically use to assess brain function. The suite of tests is designed to pick up even the smallest changes in cognitive function, something that cognitive tests to detect Alzheimer’s can’t do.
Baker says she plans to follow the people in the study for another four years to record what impact the behavior changes might have on the incidence of dementia and Alzheimer’s. About 30% of the people in the trial showed signs of amyloid, the hallmark of Alzheimer’s, in their brain scans, although they did not have any symptoms of memory loss or other cognitive deficits yet. Another third carried the APOE4 gene that increases the risk of Alzheimer’s, so Baker says following them will provide better insight into “how to improve cognition as a means of increasing resilience to decline.”
Maria Carrillo, chief scientific officer at the Alzheimer’s Association (which supported and contributed to the design of the study), says that the follow-up will also include looking at the relationship between behavior changes and Alzheimer’s medications for people who have the disease to better understand how making such lifestyle changes early might impact the disease’s severity. The researchers are also eager to study how the popular GLP-1 weight loss drugs affect cognitive decline, since some early studies hint that the drugs may help to lower inflammation associated with Alzheimer’s disease.
The rigor of the study means that doctors can, and should, start talking to their patients about making behavior changes to maintain their brain health, Carrillo says. “This could be something that if we are able to roll it out—which is our intent—through health systems, clinics and public health organizations, we could create something in which more and more individuals out there understand the impact that their everyday activities have in improving their health,” she says. “Nobody really thinks about cognitive function, and rarely do primary care doctors ask about it. This will change that.”
The good news is that even those who made changes on their own experienced some slowing in cognitive decline. That also suggests that even if people adopt part of the behavior changes—starting with their diet, for example, if they aren’t able to exercise—they might still improve their brain health. “Anything is better than nothing,” says Baker.
Jones views her new lifestyle as a positive example for her seven-year-old granddaughter, who knows that it’s not a good lunch unless it includes a salad. “She got that from grandma,” she says. She now volunteers as a community educator for the Alzheimer’s Association, helping people who are living through the same challenges she faced before joining the study.
It’s all about taking the first step, and now there’s strong evidence that the effort is worthwhile. “For people who are already doing these things, it gives them hope that they are saving their brain health, and that’s great,” says Carrillo. “For those who are halfway there, this encourages them to take it to the next level and exercise a little more or eat a little healthier. And for those on the other end of the spectrum—who aren’t following the program at all—it gives them hope that if they do certain things, they can indeed change their cognitive trajectory. It’s good news for everybody.”