13 things primary care clinics can check to help preserve brain health

Primary care clinics can play an important role in preserving patients' brain health using the American Heart Association's Life's Simple 7 as a guide, as well as addressing 6 other factors associated with cognitive decline, according to a new American Stroke Association/American Heart Association Scientific Statement. "A Primary Care Agenda for Brain Health," published today in the Associations' journal Stroke.

Preserving brain health in an aging population is a growing concern in the U.S. An estimated one in five Americans 65 years and older has mild cognitive impairment, and one in seven has dementia. By 2050, the number of Americans with dementia is expected to triple, the statement authors note.

"Primary care is the right home for practice-based efforts to prevent or postpone cognitive decline. Primary care professionals are most likely to identify and monitor risk factors early and throughout the lifespan," said Chair of the scientific statement writing group Ronald M. Lazar, Ph.D., FAHA, the Evelyn F. McKnight Endowed Chair for Learning and Memory in Aging and director of the Evelyn F. McKnight Brain Institute at the University of Alabama at Birmingham School of Medicine. "Prevention doesn't start in older age; it exists along the health care continuum from pediatrics to adulthood. The evidence in this statement demonstrates that early attention to these factors improves later life outcomes."

Life's Simple 7 focuses on seven lifestyle targets to achieve ideal cardiovascular health: managing blood pressure, healthy cholesterol levels, reducing blood sugar, increasing physical activity, eating better, losing weight and not smoking. The new statement suggests primary care professionals also consider assessing risk factors to address cognitive health. The six risk factors to consider, in addition to Life's Simple 7, that impact optimal brain health are depression, social isolation, excessive alcohol use, sleep disorders, less education and hearing loss. The statement lists risk factors for cognitive impairment, prevention strategies and best practices to integrate brain health prevention into primary care.

"Scientists are learning more about how to prevent cognitive decline before changes to the brain have begun. We have compiled the latest research and found Life's Simple 7 plus other factors like sleep, mental health and education are a more comprehensive lifestyle strategy that optimizes brain health in addition to cardiovascular health," said Lazar, who is also a professor of neurology and neurobiology at the University of Alabama at Birmingham.

The statement uses cognition to define brain health, referring to the spectrum of intellectual-related activities, such as memory, thinking, reasoning, communication, and problem solving that enables people to thrive and navigate the world on an everyday basis. The ability to think, solve problems, remember, perceive and communicate are crucial to successful living; their loss can lead to helplessness and dependency.

"Studies have shown that these domains are impacted by factors that are within our control to change," Lazar said. "Prevention and mitigation are important, because once people have impaired cognition, the current treatment options are very limited."

According to the statement:

• Recent data show that hypertension, diabetes and smoking in adulthood and middle-life increase the odds of cognitive decline in middle-age and accelerate cognitive decline in older age.
• People with dementia experience lower quality of life, and caregivers—typically family members—experience high rates of psychological stress and physical ill-health. Dementia is more costly than heart disease or cancer, with worldwide costs estimated at $818 billion in 2015.
• Primary care is the right place for practice-based efforts to prevent or postpone cognitive decline. This setting can provide comprehensive coordinated care to promote AHA's Life's Simple 7 as a guide for brain health and overall wellness.
• Professional guidelines also recommend routine screening for depression and counseling patients to focus on healthy eating and exercising a minimum of 150 minutes a week.
• Implementation of practices to prevent cognitive decline often fall short—referred to as an evidence-practice gap. However, new practices and technology like telehealth, which are more common as a result of the COVID-19 pandemic, are addressing this gap.
• Lack of access to primary care services may be a barrier to prevention. Even with the Affordable Care Act, an estimated 15% of Americans adults still lack health insurance, and 25% of Americans do not have a source of primary care.

"Many people think of high blood pressure, Type 2 diabetes and other risk factors as affecting only heart health, yet these very same risk factors affect our brain health. Patients might be more likely to pay attention to the importance of addressing modifiable risk factors if they understood the links," Lazar said. "I've given lectures, and what people tell me is, the one thing they do not want to lose during the course of their lives is their mind."

In 2017, the American Stroke Association/American Heart Association issued a presidential advisory on achieving optimal brain health that includes Life's Simple 7.

The American Heart Association and the Paul G. Allen Frontiers Group together with additional contributors, including the Oskar Fischer Project and Henrietta B. and Frederick H. Bugher Foundation, have committed over $43 million to fund research with the potential to move forward brain health and cognitive impairment science. The American Heart Association/Allen Initiative in Brain Health and Cognitive Impairment has granted 3 competitive basic science research awards to study brain health over eight years.

This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association's Stroke Council, and the American Academy of Neurology affirms the value of the statement, additionally, as an educational tool for neurologists.