Summary

People forget things—a name, where they put their keys, a phone number—and yet what is dismissed as a minor inconvenience at 25 years of age can evolve into a momentary anxiety at 35, and a major source of personal worry at age 55 or 60. Forgetfulness at older ages is often equated with a decline in cognition—a public health issue that goes beyond memory lapses and one that can have significant impacts on independent living and healthy aging. The term “cognition” covers many mental abilities and processes, including decision making, memory, attention, and problem solving. Collectively, these different domains of cognition are critical for successfully engaging in the various activities involved in daily functioning such as paying household bills, following a recipe to cook a meal, and driving to a doctor’s appointment. As human life expectancy increases, maintaining one’s cognitive abilities is key to assuring the quality of those added years.

Cognitive aging is a public health concern from many perspectives. Individuals are deeply concerned about declines in memory and decision-making abilities as they age and may also be worried about whether these declines are early signs of a neurodegenerative disease, particularly Alzheimer’s disease. They may fear that cognitive decline will lead to a loss of independence and a reduced quality of life and health. In a 2012 survey of its members, AARP found that “staying mentally sharp” was a top concern of 87 percent of respondents. Cognitive decline affects not only the individual but also his or her family and community, and an array of health, public health, social, and other services may be required to provide necessary assistance and support. Lost independence may stem from im-

paired decision making, which can reduce an individual’s ability to drive or increase the individual’s vulnerability to financial abuse or exploitation. Cognitive impairment also affects society and the public’s quality of life.

At this point in time, when the older population is rapidly growing in the United States and across the globe, it is important to carefully examine what is known about cognitive aging, to identify the positive steps that can be taken to maintain and improve cognitive health, and then to take action to implement those changes by informing and activating the public, the health sector, nonprofit and professional associations, the private sector, and government agencies. In the past several decades rapid gains have been made in understanding the non-disease changes in cognitive function that may occur with aging and in elucidating the range of cognitive changes, from those that are normal with aging to those that are the result of disease; much remains to be learned yet the science is readily advancing.

This Institute of Medicine (IOM) study examines cognitive aging, a natural process associated with advancing years. The IOM committee was charged with assessing the public health dimensions of cognitive aging with an emphasis on definitions and terminology, epidemiology and surveillance, prevention and intervention, education of health professionals, and public awareness and education.

WHAT IS COGNITIVE AGING?

This report focuses on one aspect of health in older adults—cognitive health. Cognition refers to the mental functions involved in attention, thinking, understanding, learning, remembering, solving problems, and making decisions. It is a fundamental aspect of an individual’s ability to engage in activities, accomplish goals, and successfully negotiate the world. Although cognition is sometimes equated with memory, cognition is multidimensional because it involves a number of interrelated abilities that depend on brain anatomy and physiology. Distinguishing among these component abilities is important since they play different roles in the processing of information and behavior and are differentially impacted by aging.

The committee provides a conceptual definition of cognitive aging as a process of gradual, ongoing, yet highly variable changes in cognitive functions that occur as people get older. Cognitive aging is a lifelong process. It is not a disease or a quantifiable level of function. However, for the purposes of this report the focus is primarily on later life. In the context of aging, cognitive health is exemplified by an individual who maintains his or her optimal cognitive function with age.

Box S-1 provides the committee’s characterization of cognitive aging. Cognitive aging is too complex and nuanced to define succinctly, and therefore it is appropriately characterized through this longer description. Efforts

are needed to develop operational definitions of cognitive aging in order to allow comparisons across studies.

CHARACTERIZING AND ASSESSING COGNITIVE AGING

Age-related changes in cognition are highly variable from one individual to the next. This variability is explained in part by differences in life experience, health status, lifestyles, education, attitudinal and emotional factors, socioeconomic status, and genetics. The trajectory of cognitive change also varies for different cognitive functions—memory, decision making, learning, speed of processing, and so on. Further, older age is not associated only with decline; some aspects of cognition, such as wisdom, remain stable in the older decades and aspects of intelligence, such as knowledge, may actually increase with age until the very later decades.

A wide variety of tools and measures are available to test for cognitive change; however, not all may be relevant to real-world activities. Studies use different methods, measures, and definitions that make comparison difficult, and the cognitive aging literature has some significant gaps. Studies of brain tissue in both humans and in animal models have sought to examine the underlying neural mechanisms that may be responsible for the age-related changes in cognition. These include studies of neuronal number, synaptic integrity, and neurotransmitter changes. Overall, they show that neuronal number remains relatively stable, although changes do occur in neuronal structure and neurotransmitter receptors. (The stability in the number of neurons—that is, the lack of neuron death in areas supporting cognition—seen with aging is in contrast to the extensive neuron loss that occurs in Alzheimer’s disease.)

• Studies to examine the mechanisms underlying interventions that affect the cognitive trajectory;
• Studies to identify and validate novel tools and measures of function that capture the complexities of real-world tasks and are sensitive to early changes in cognition and function; and
• An update of the norms for cognitive function in older adults (including those in the most advanced age groups) to include the consideration of disease, literacy, language, racial and ethnic diversity, culture, and socioeconomic factors.

UNDERSTANDING THE POPULATION IMPACT

While a great deal of research has examined the occurrence, causes, natural history, pathogenesis, and clinical management of dementia, including Alzheimer’s disease, less attention has been paid to cognitive aging per se, particularly from a public health perspective. Population-based information about the nature and extent of cognitive aging provides a basis for building public awareness and understanding and can be used to engage individuals and their families in maintaining cognitive health; to inform health care professionals, financial professionals, and others as they educate and advise their older patients and clients; and to guide program development and implementation.

• Expanded data collection efforts and further analyses of representative surveys involving geographically diverse and high-risk populations. These efforts should include cognitive testing when standardized, feasible, and clinically credible and also self-reports of perceptions or concerns regarding cognitive aging, personal and social adaptations, and self-care and other management practices.
• Longitudinal assessments of changes in cognitive performance and risk behaviors in diverse populations.
• Inclusion of cognition-related questions in the core instrument of the Behavioral Risk Factor Surveillance System, rather than an optional module.
• Exploration of other available relevant data on cognitive health such as health insurance claims data, sales and marketing data for cognition-related products and treatments, data on financial and banking transactions as well as on financial fraud and scams, and data on automobile insurance claims.
• Active dissemination of data on cognitive aging in the population. An annual or biennial report to the U.S. public should be issued by the CDC or other federal agency on the nature and extent of cognitive aging in the U.S. population.

REDUCING RISKS AND DEVELOPING INTERVENTIONS

The brain is subject to a lifetime of demands and exposures, both beneficial and deleterious. Given the importance to the public’s health of preventing individuals’ cognitive impairment and promoting their cognitive health, it is important to develop an in-depth understanding of these various beneficial and deleterious factors to guide prevention and remediation efforts. However, much remains to be learned about the relationship between lifestyle and risk factors and the maintenance of cognitive health throughout the adult life span. While many studies have examined dementia-based outcomes, few have examined non-dementia-related cognitive changes. Most of the interventions developed to date focus on prevention, although researchers are exploring some remediation strategies. For products that claim to enhance cognitive function or to maintain current levels of function (including cognitive training products, nutriceuticals, supplements, or medications), a review of policies and regulatory guidance is needed. Although there is wide variability in cognitive function among individuals, a number of specific actions can be taken to maintain cognitive health and reduce the effects of cognitive aging.

• Conduct single- and multicomponent clinical trials of promising interventions to promote cognitive health and prevent cognitive decline, testing for both cognitive status and functional outcomes.
• Assess cognitive outcomes in clinical trials that target the reduction of cardiovascular and other risk factors likely related to cognitive health.
• Explore older adults’ preferences and values regarding cognitive health and aging and regarding specific cognitive interventions and training modalities.
• Identify effective approaches to sustaining behavior changes that promote healthy cognition across the life span.

Recommendation 5: Ensure Appropriate Review, Policies, and Guidelines for Products That Affect Cognitive Function or Assert Claims Regarding Cognitive Health

The Food and Drug Administration and the Federal Trade Commission, in conjunction with other relevant federal agencies and consumer organizations, should determine the appropriate regulatory review, policies, and guidelines for

• over-the-counter medications (such as antihistamines, sedatives, and other medications that have strong anticholinergic activity) that may affect cognitive function, and
• interventions (such as cognitive training, nutriceuticals, supplements, or medications) that do not target a disease but may assert claims about cognitive enhancement or maintaining cognitive abilities such as memory or attention.

IMPROVE HEALTH CARE PROFESSIONAL EDUCATION AND USE OF WELLNESS VISITS

As a result of the aging of the population, older adults constitute an increasingly larger portion of the patients seen by health care professionals both in acute and ambulatory care settings. Moreover, with increased public awareness of and concern about cognitive impairment and dementia in older age, individuals and families are turning to health care professionals for information and advice about brain health. Health care professionals are trusted sources of information on cognitive aging and need to be fully informed and ready to respond to patient queries. Further efforts are needed by health professional schools, continuing education organizations, and professional associations to establish and reinforce the core competencies needed to respond to patient and family concerns about cognitive aging as well to proactively recommend effective steps to maximize cognitive health.

Furthermore, attention needs to be paid to certain medications that may cause cognitive impairment as well as to delirium and associated cognitive decline that may occur in older adults during hospitalization and post-surgery recovery.

In addition, other components of the health care system have a cognitive health promotion role:

• CMS should develop and implement demonstration projects to identify best practices for clinicians in assessing cognitive change and functional impairment and in providing appropriate counseling and prevention messages during, for example, the Medicare Annual Wellness Visit or other health care visits.
• Health care systems and private and public health insurance companies should develop evidence-based programs and materials on cognitive health across the life span.
• During and after hospital stays and post-surgery, health care providers, patients, and families should be alert to potential cognitive changes and delirium.

COMMUNITY ACTIONS: HEALTH, FINANCES, DRIVING, TECHNOLOGY, AND CONSUMER DECISIONS

Cognitive aging can affect everyday life for older adults and their families. These effects can manifest themselves as decreased judgment in determining when to make a left turn while in a busy intersection, uncertainty about whether a new financial investment is a wise choice or a financial scam, or determining the best way to take care of one’s overall health. Furthermore, cognitive aging has significant impacts on society. In addition to significant financial losses (that older adults lose an estimated $2.9 billion per year, directly and indirectly, to financial fraud), an array of health, public health, social, and other services may be required to provide necessary assistance and support. Improving the quality of life for older adults is a societal value that for cognitive aging has widespread consequences and requires action in many sectors.

Communities across the country have been working to improve independence, health, and quality of life for older adults. Efforts are under way in many areas, but challenges remain in knowing how best to help older adults identify and address the potential impacts of cognitive aging.

help individuals and families make more informed decisions regarding cognitive health.

Specifically,

• A central, user-friendly, easily navigated website should be available to provide independent, evidence-based information and links relevant to cognitive aging, including information on the promotion of protective behaviors and links to effective programs and services. The information should be presented in a way that takes health literacy into account.
• Consumer-relevant criteria should be developed and widely disseminated to provide individuals and families with guidance on evaluating cognition-related products (e.g., cognitive training products, nutriceuticals, and medications).

Recommendation 9: Expand Services to Better Meet the Needs of Older Adults and Their Families with Respect to Cognitive Health Relevant federal and state agencies (including the Administration for Community Living [ACL], the Centers for Disease Control and Prevention [CDC], the National Highway Traffic Safety Administration [NHTSA], and the Consumer Financial Protection Bureau), nonprofit organizations (such as the Financial Industry Regulatory Authority), professional associations, and relevant private-sector companies and consumer organizations should develop, expand, implement, and evaluate programs and services used by older adults relevant to cognitive aging with the goal of helping older adults avoid exploitation, optimize their independence, improve their function in daily life, and aid their decision making.

Specifically,

• Financial decision making:
  • The banking and financial services industries and state and federal banking and financial regulators should develop and disseminate banking and financial policies, services, and information materials that assist older adults and their families in making decisions that meet their financial means and objectives, that reduce the opportunities for unsuitable decisions, and that mitigate the harms of such decisions.
  • Surrogacy mechanisms, such as powers of attorney or multiparty accounts should have appropriate safeguards to protect the interests of the older adult.
  • The financial services industries and relevant state and federal agencies should develop, strengthen, and implement systems approaches, best practices, training, and

• • laws and regulations to help verify that financial transactions are not fraudulent or the result of diminished capacity or undue influence.
  • Systems should be strengthened for reporting or taking other protective actions against potential financial fraud, exploitation, or abuse to relevant enforcement and investigative officials. Laws and regulations should be revised to mitigate civil liability and professional harms resulting from such protective actions.
• Driving and transportation:
  • NHTSA, states’ departments of motor vehicles, and relevant professional and consumer organizations such as the American Automobile Association should expand, validate, and disseminate tools and informational materials to assist older adults in maintaining and assessing their driving skills and to assist older adults and their families in making decisions about safe driving.
  • The automobile industry should expand and evaluate technologies that enhance decision making and safety for older drivers.
  • State and local transportation authorities, local planning commissions, private developers, and community groups should expand efforts to develop and implement alternative transportation options to accommodate changes that occur with cognitive aging, including efforts to ensure safe and walkable communities.

• Technology:
  • Technology industries should develop and adapt hardware, software, and emerging technologies to accommodate the needs of older adults that are related to cognitive aging.
  • The CDC, ACL, and other relevant agencies, organizations, and private-sector companies should support evidence-based programs that educate older adults in the use of emerging technologies.

• Health information:
  • Health information providers, including private-sector companies and government agencies, should ensure that their websites (including patient health portals), packaging (including medication packaging), and other consumer health information relevant to cognitive aging meet health literacy standards.

EXPAND PUBLIC EDUCATION AND ENGAGEMENT

Meeting the public health goal of maintaining cognitive health requires clear and effective communication featuring accurate, up-to-date, and consistent messages that resonate with individuals and their communities and encourage behavior that promotes cognitive health. Attention needs to be paid to whether different segments of the population are exposed to relevant information, persuaded to act accordingly, and have the environmental supports in place to change and maintain behaviors that are supportive of cognitive health. Since new research findings are constantly becoming available, stakeholders also need a reliable means of keeping up with this rapidly changing field.

As noted throughout this report, cognitive aging is not synonymous with Alzheimer’s disease. Major challenges for public information campaigns about cognitive aging are to differentiate the messages from those about Alzheimer’s disease and other dementias and to promote actions to enhance or maintain cognitive health and to prevent or reduce cognitive decline.

• munication strategies for the key messages among the target groups;
• Be updated as new evidence is gained on cognitive aging;
• Emphasize a lifelong approach to cognitive health;
• Promote succinct and actionable key messages that are understandable, memorable, and relevant to the target groups;

• Focus on sustaining changes in behaviors that promote cognitive health; and
• Promote effective evidence-based tools for maintenance of cognitive health and cognitive change assessment, as well as the information gateway on cognitive aging (see Recommendation 8).

OPPORTUNITIES FOR ACTION

Aging is inevitable, but individuals, families, communities, and society can take actions that may help prevent or ameliorate the impact of aging on cognition, create greater understanding about its impact, and help older adults live fuller and more independent lives. One of the major concerns of older adults is “Will I stay sharp?” Although changes in cognitive function vary widely among individuals, there are a number of actions that would make a difference and promote cognitive health; these are summarized in Box S-2 and detailed throughout the discussion and recommendations in this report. Cognitive aging is not just an individual or family or health care system challenge—it is an issue that affects the fabric of society and requires actions by many and varied stakeholders. How society responds to these challenges will reflect the value it places on older adults and how it views their continued involvement and contribution to their families, social networks, and communities.

The committee heard throughout its work on this study that cognitive aging is a concern to many people across all cultural groups and income levels. In recent years a vigorous public health, research, and community response has focused on Alzheimer’s disease and other neurodegenerative dementias. These efforts should continue to be strengthened. At the same time, similar efforts should be made in the field of cognitive aging. Attention needs to be paid to the cognitive vulnerabilities of the vast majority of older adults who may experience cognitive decline that is not caused by a neurodegenerative disease. They, too, want to maintain their cognitive health to the fullest extent possible. The committee hopes that a commitment to addressing cognitive aging by many sectors of society will bring about further effective interventions, greater understanding of risk and protective factors, and a society that values and sustains cognitive health.