Conference Coverage

AHA and ASA Offer Recommendations for Maintaining Brain Health

An expert panel suggests that control of cardiovascular risks and social engagement can preserve cognition.

Neurology Reviews. 2018 April;26(4):48

LOS ANGELES—Modifying cardiovascular risk factors in midlife may help to prevent or delay cognitive impairment, according to an overview presented at the International Stroke Conference 2018. This conclusion comes from a presidential advisory published by the American Heart Association (AHA) and the American Stroke Association (ASA) that also defines optimal brain health.

“By prevention or control of cardiovascular and behavioral health risks, in addition to prevention of heart attack and stroke, we may be able to prolong cognitive vitality and prevent cognitive decline or dementia as we age,” said Philip Gorelick, MD, MPH, Professor of Translational Science and Molecular Medicine at Michigan State University College of Human Medicine in Grand Rapids, and an author of the advisory. “Further study through clinical trials is necessary to support the contention that we can prevent cognitive decline and dementia. However, observational epidemiological studies support the premise.”

Philip Gorelick, MD, MPH

Decades of Evidence

Decades of research preceded the AHA/ASA effort to draft a presidential advisory. In a 1999 literature review, Dr. Gorelick and colleagues found that modifying cardiovascular risk factors in midlife might delay or prevent vascular causes of cognitive impairment or Alzheimer’s disease.

Casserly and Topol in 2004 found that Alzheimer’s disease and atherosclerosis shared common risk factors. Many of the factors, such as hypercholesterolemia, hypertension, hyperhomocysteinemia, diabetes, metabolic syndrome, and smoking, relate to cardiovascular risks.

In the 2006 Honolulu–Asia Aging Study, Willcox et al found that avoidance of overweight status, hyperglycemia, hypertension, smoking, and excessive alcohol consumption were associated with survival and cognitive health. “The Honolulu–Asia Aging Study was one of the first epidemiological studies to show that healthy lifestyle and a beneficial cardiovascular risk profile in midlife were linked to good cognitive and functional outcomes later in life,” said Dr. Gorelick.

In 2017, Allen et al found that a favorable cardiovascular risk profile at younger ages extended survival by nearly four years and postponed the onset of all-cause morbidity by four and a half years.

A Definition of Optimal Brain Health

The AHA and ASA convened an expert panel to provide an initial definition of optimal brain health in adults and offer guidance on how to maintain brain health. The panel also investigated the impact of cognitive impairment on public health. A review of the relevant literature formed the basis of the panel’s advisory.

The group based its definition of optimal brain health on the AHA’s list of “Life’s Simple Seven.” These seven factors include nonsmoking status, physical activity, healthy diet consistent with current guidelines, BMI lower than 25 kg/m², untreated blood pressure lower than 120/80 mm Hg, untreated total cholesterol level lower than 200 mg/dL, and fasting blood glucose level lower than 100 mg/dL. The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study previously had indicated that the more of these factors a patient achieves, the more likely his or her cognition will be preserved.

“This work in defining optimal brain health in adults serves to provide the AHA/ASA with a foundation for a new strategic direction going forward in cardiovascular health promotion and disease prevention,” said Dr. Gorelick and colleagues.

Recommendations for Preserving Cognitive Health

The presidential advisory recommends that individuals follow AHA/ASA guidelines on stroke and cardiovascular disease to maintain cognitive health. The authors also endorsed recommendations from the Institute of Medicine, which include social and intellectual engagement, adequate sleep and treatment for sleep disorders, steps to avoid cognitive changes due to delirium if hospitalized, and regularly discussing and reviewing health conditions and medications that might influence cognitive health with a health care professional.

“Maintaining optimal brain health requires actions by individuals, health care practitioners, public health organizations, policy makers, and the private sector,” said Dr. Gorelick and colleagues.

Current Research and Recommendations

The AHA/ASA presidential advisory was published in October 2017, and new research on cognitive and brain health has since emerged. In December 2017, the Lancet Commission on Dementia Prevention, Intervention, and Care recommended active treatment of hypertension in middle-aged and older adults. They also concluded that one-third of all cases of dementia could be delayed or prevented through interventions such as childhood education, exercise, maintenance of social engagement, reduction of smoking, and management of hearing loss, depression, diabetes mellitus, and obesity.

In January, a series of systematic analyses funded by the Agency for Healthcare Research and Quality found insufficient evidence to support pharmacologic treatments or over-the-counter supplements for cognitive protection in individuals with normal cognition or mild cognitive impairment. The analyses also found insufficient evidence to support short-term, single-component physical activity interventions to promote cognitive function and prevent cognitive decline or dementia in older adults. Evidence also did not support cognitive training to prevent or delay cognitive decline or dementia.

—Erica Tricarico