Economic Evaluation of Exercise or Cognitive and Social Enrichment Activities for Improved Cognition After Stroke.

Importance: Cognitive impairment is prevalent in survivors of stroke, affecting approximately 30% of individuals. Physical exercise and cognitive and social enrichment activities can enhance cognitive function in patients with chronic stroke, but their cost-effectiveness compared with a balance and tone program is uncertain. Objective: To conduct a cost-effectiveness and cost-utility analysis of multicomponent exercise or cognitive and social enrichment activities compared with a balance and tone program. Design, Setting, and Participants: This economic evaluation used a Canadian health care systems perspective and the Vitality study, a randomized clinical trial aimed at improving cognition after stroke with a 6-month intervention and a subsequent 6-month follow-up (ie, 12 months). The economic evaluation covered the duration of the Vitality trial, between June 6, 2014, and February 26, 2019. Participants were community-dwelling adults aged 55 years and older who experienced a stroke at least 12 months prior to study enrollment in the Vancouver metropolitan area, British Columbia, Canada. Data were analyzed from June 1, 2022, to March 31, 2023. Interventions: Participants were randomly assigned to twice-weekly classes for 1 of the 3 groups: multicomponent exercise program, cognitive and social enrichment activities program, or a balance and tone program (control). Main Outcomes and Measures: The primary measures for the economic evaluation included cost-effectiveness (incremental costs per mean change in cognitive function, evaluated using the Alzheimer Disease Assessment Scale-Cognitive-Plus), cost-utility (incremental cost per quality-adjusted life-year gained), intervention costs, and health care costs. Since cognitive benefits 6 months after intervention cessation were not observed in the primary randomized clinical trial, an economic evaluation at 12 months was not performed. Results: Among 120 participants (mean [SD] age, 71 [9] years; 74 [62%] male), 34 were randomized to the multicomponent exercise program, 34 were randomized to the social and cognitive enrichment activities program, and 52 were randomized to the balance and tone control program. At the end of the 6-month intervention, the cost per mean change in Alzheimer Disease Assessment Scale-Cognitive-Plus score demonstrated that exercise was more effective and costlier compared with the control group in terms of cognitive improvement with an incremental cost-effectiveness ratio of CAD -$8823. The cost per quality-adjusted life-year gained for both interventions was negligible, with exercise less costly (mean [SD] incremental cost, CAD -$32 [$258]) and cognitive and social enrichment more costly than the control group (mean [SD] incremental cost, CAD $1018 [$378]). The balance and tone program had the lowest delivery cost (CAD $777), and the exercise group had the lowest health care resource utilization (mean [SD] $1261 [$1188]) per person. Conclusions and Relevance: The findings of this economic evaluation suggest that exercise demonstrated potential for cost-effectiveness to improve cognitive function in older adults with chronic stroke during a 6-month intervention.

Using the Health Belief Model to Understand Age Differences in Perceptions and Responses to the COVID-19 Pandemic.

COVID-19 severity and mortality risk are greater for older adults whereas economic impact is deeper for younger adults. Using the Health Belief Model (HBM) as a framework, this study used a web-based survey to examine how perceived COVID-19 susceptibility and severity and perceived efficacy of recommended health behaviors varied by age group and were related to the adoption of health behaviors. Proportional odds logistic regression was used to examine the relationship between age group and perceived COVID-19 susceptibility, severity, impact, and health behavior efficacy and adoption. Structural equation modeling based on HBM constructs examined the relationships between health beliefs and behaviors. Data from 820 participants (Ontario, Canada) were analyzed (age: 42.7, 16.2 years; 79% women). Middle-aged and older adults reported greater concerns about the personal risk of hospitalization and mortality, economic impact, and social impact of COVID-19 than young adults. Middle-aged adults also reported greatest concern for other age groups. Adoption and perceived efficacy of health behaviors was similar across age groups with few exceptions. Both middle-aged and older-adults were more likely to perceive their own and each other's age groups as responding adequately to COVID-19 compared to young adults. Structural equation modeling indicated perceived benefits of health behaviors were the primary driver of behavior uptake, with socioeconomic factors and perceived severity and susceptibility indirectly associated with uptake through their influence on perceived benefits. Overall, these results suggest adoption of health behaviors is very high with few differences between age groups, despite differences in perceived impact of COVID-19. Public health communications should focus on the benefits of health behaviors to drive adoption.

Dementia- and mild cognitive impairment-inclusive exercise: Perceptions, experiences, and needs of community exercise providers.

PURPOSE: For persons who are at risk for, or living with, dementia exercise is recommended, yet many become or remain inactive. Exercise providers play a vital role in promoting and facilitating exercise in these groups by recognizing and being responsive to the needs of persons with mild cognitive impairment (MCI) or dementia in exercise programming. The objective of this study was to explore the experiences, perceptions, and needs of community exercise providers regarding dementia. MATERIALS & METHODS: Five focus groups were held with community exercise providers (n = 30) who deliver exercise to older adults (≥55 years) in municipal, non-profit, for profit, or academic settings. RESULTS: Three themes were developed: (1) Unique experiences and diverse perceptions: suggests unique personal experiences with MCI and dementia inform distinct perceptions of dementia; (2) Dementia-Inclusive Practices: learning as you go and adapting for the individual: reflects exercise providers' approaches to recognizing and accommodating individuals' unique abilities and preferences; (3) Training and Best Practices, with Flexibility: identifies exercise providers' desires for MCI- and dementia-specific knowledge and training strategies, which need to recognize dementia heterogeneity between and within persons over time. CONCLUSIONS: These findings highlight a willingness of exercise providers to support dementia-inclusive exercise, but recognize they have minimal training and lack educational resources to do so. Formal training resources may enhance exercise accessibility and participation for persons with MCI or dementia.

Interdisciplinary and Collaborative Approaches Needed to Determine Impact of COVID-19 on Older Adults and Aging: CAG/ACG and CJA/RCV Joint Statement.

The COVID-19 pandemic and subsequent state of public emergency have significantly affected older adults in Canada and worldwide. It is imperative that the gerontological response be efficient and effective. In this statement, the board members of the Canadian Association on Gerontology/L'Association canadienne de gérontologie (CAG/ACG) and the Canadian Journal on Aging/La revue canadienne du vieillissement (CJA/RCV) acknowledge the contributions of CAG/ACG members and CJA/RCV readers. We also profile the complex ways that COVID-19 is affecting older adults, from individual to population levels, and advocate for the adoption of multidisciplinary collaborative teams to bring together different perspectives, areas of expertise, and methods of evaluation in the COVID-19 response.

Study protocol for Vitality: a proof-of-concept randomised controlled trial of exercise training or complex mental and social activities to promote cognition in adults with chronic stroke.

INTRODUCTION: Cerebrovascular disease-such as stroke-is the second most common cause of dementia (ie, vascular dementia). Specifically, a stroke increases one's risk for dementia by a factor of two. Thus, stroke survivors represent a target population in need of intervention strategies to promote cognitive function and prevent dementia. The current standard of care in stroke rehabilitation does not adequately address the significant cognitive consequences of stroke, especially for those who are in the chronic phase (ie, >12 months since an index stroke). Two potential intervention strategies are: (1) exercise training and (2) cognitive and social enrichment activities. METHODS AND ANALYSIS: The aim of this proof-of-concept randomised controlled trial is to determine whether a 6-month targeted exercise training programme or a 6-month cognitive and social enrichment programme can efficaciously and efficiently improve cognitive function in older adults with chronic stroke compared with a 6-month stretch and tone programme (ie, control). The primary measurement periods will be baseline, month 6 (postintervention) and month 12 (6-month follow-up). The primary outcome measure will be performance on the Alzheimer's Disease Assessment Scale-Cognitive-Plus (ADAS-Cog-Plus), a global measure of cognitive performance using multidimensional item response theory to summarise scores from the 13-item ADAS-Cog and other standard cognitive assessments. The primary analysis will compare changes in ADAS-Cog-Plus performance from baseline to month 6. Proof-of-concept outcomes relating to intervention feasibility will be analysed descriptively. The economic evaluation will examine the incremental costs and health outcome benefits generated by both interventions versus the control. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the University of British Columbia's Clinical Research Ethics Board (H13-00715, 26 July 2013). Any modifications to the protocol will require a formal amendment to the protocol and approval by the Research Ethics Board. Outcomes of this randomised controlled trial and the statistical code to generate those outcomes will be disseminated through publication in peer-reviewed journals as well as conference presentations. TRIAL REGISTRATION NUMBER: NCT01916486.

Criterion and convergent validity of the Montreal cognitive assessment with screening and standardized neuropsychological testing.

OBJECTIVES: To compare the validity of the Montreal Cognitive Assessment (MoCA) with the criterion standard of standardized neuropsychological testing and to compare the convergent validity of the MoCA with that of existing screening tools and global measures of cognition. DESIGN: Cross-sectional observational study. SETTING: Tertiary care hospital-based cognitive neurology subspecialty clinic. PARTICIPANTS: A convenience sample of 107 individuals with mild Alzheimer's disease (AD, n=75) or mild cognitive impairment (MCI, n=32) from the Sunnybrook Dementia Study. MEASUREMENTS: In addition to the MoCA, all participants completed the Mini-Mental State Examination (MMSE), the Mattis Dementia Rating Scale (DRS), and detailed neuropsychological testing. RESULTS: Convergent validity was supported, with MoCA scores correlating well with the MMSE (correlation coefficient (r)=0.66, P<.001) and the DRS (r=0.77, P<.001) and the MoCA better associated with the DRS than did the MMSE. Criterion validity was supported, with MoCA subscores according to cognitive domain correlating well with analogous neuropsychological tests and, in the case of memory (area under the receiver operating characteristic curve (AUC)=0.86), executive (AUC=0.79), and visuospatial function (AUC=0.79), being reasonably sensitive to impairment in those domains. CONCLUSION: The MoCA is a valid assessment of cognition that shows good agreement with existing screening tools and global measures (convergent validity) and was superior to the MMSE in this regard. The MoCA domain-specific subscores align with performance on more-detailed neuropsychological tests, suggesting not only good criterion validity for the MoCA, but also that it may be useful in guiding further neuropsychological testing.

Activity energy expenditure and incident cognitive impairment in older adults.

BACKGROUND: Studies suggest that physically active people have reduced risk of incident cognitive impairment in late life. However, these studies are limited by reliance on self-reports of physical activity, which only moderately correlate with objective measures and often exclude activity not readily quantifiable by frequency and duration. The objective of this study was to investigate the relationship between activity energy expenditure (AEE), an objective measure of total activity, and incidence of cognitive impairment. METHODS: We calculated AEE as 90% of total energy expenditure (assessed during 2 weeks using doubly labeled water) minus resting metabolic rate (measured using indirect calorimetry) in 197 men and women (mean age, 74.8 years) who were free of mobility and cognitive impairments at study baseline (1998-1999). Cognitive function was assessed at baseline and 2 or 5 years later using the Modified Mini-Mental State Examination. Cognitive impairment was defined as a decline of at least 1.0 SD (9 points) between baseline and follow-up evaluations. RESULTS: After adjustment for baseline Modified Mini-Mental State Examination scores, demographics, fat-free mass, sleep duration, self-reported health, and diabetes mellitus, older adults in the highest sex-specific tertile of AEE had lower odds of incident cognitive impairment than those in the lowest tertile (odds ratio, 0.09; 95% confidence interval, 0.01-0.79). There was also a significant dose response between AEE and incidence of cognitive impairment (P = .05 for trend over tertiles). CONCLUSIONS: These findings indicate that greater AEE may be protective against cognitive impairment in a dose-response manner. The significance of overall activity in contrast to vigorous or light activity should be determined.

Promising strategies for the prevention of dementia.

The incidence and prevalence of dementia are expected to increase several-fold in the coming decades. Given that the current pharmaceutical treatment of dementia can only modestly improve symptoms, risk factor modification remains the cornerstone for dementia prevention. Some of the most promising strategies for the prevention of dementia include vascular risk factor control, cognitive activity, physical activity, social engagement, diet, and recognition of depression. In observational studies, vascular risk factors-including diabetes, hypertension, dyslipidemia, and obesity-are fairly consistently associated with increased risk of dementia. In addition, people with depression are at high risk for cognitive impairment. Population studies have reported that intake of antioxidants or polyunsaturated fatty acids may be associated with a reduced incidence of dementia, and it has been reported that people who are cognitively, socially, and physically active have a reduced risk of cognitive impairment. However, results from randomized trials of risk factor modification have been mixed. Most promising, interventions of cognitive and physical activity improve cognitive performance and slow cognitive decline. Future studies should continue to examine the implication of risk factor modification in controlled trials, with particular focus on whether several simultaneous interventions may have additive or multiplicative effects.

The psychosocial effects of deployment on military children.

OBJECTIVE: The impact of the Global War on Terror on two million U.S. military children remains unknown. The purpose of this study was to describe the psychosocial profile of school age children during parental deployment utilizing standardized psychosocial health and stress measures, and to identify predictors of children at "high risk" for psychosocial morbidity during wartime deployment. METHODS: Army spouses with a deployed service member and a child aged 5-12 years completed a deployment packet consisting of demographic and psychosocial questions. The psychosocial health measures included the Pediatric Symptom Checklist (PSC), the Parenting Stress Index-Short Form and the Perceived Stress Scale-4. RESULTS: Overall, 32% of respondents exceeded the PSC cut off score for their child, indicating "high risk" for psychosocial morbidity and 42% reported "high risk" stress on the Parenting Stress Index-Short Form. Parenting stress significantly predicted an increase in child psychosocial morbidity (odds ratio 7.41, confidence interval 2.9-19.0, p < 0.01). Parents utilizing military support reported less child psychosocial morbidity (odds ratio 0.32, confidence interval 0.13-0.77, p < 0.01) and parental college education was related to a decrease in child psychosocial morbidity (odds ratio 0.33, confidence interval 0.13-0.81, p < 0.02). The effects of military rank, child gender, child age, and race or ethnic background did not reach statistical significance. CONCLUSION: Families in this study experiencing deployment identified one-third of military children at "high risk" for psychosocial morbidity. The most significant predictor of child psychosocial functioning during wartime deployment was parenting stress. Military, family and community supports help mitigate family stress during periods of deployment.

Modeling the impact of sex on how exercise is associated with cognitive changes and death in older Canadians.

BACKGROUND: Exercise improves cognition and lessens the risk of death in older adults. Cognition and mortality are each also affected by biological sex, which might modify the effect of exercise. We investigated how sex mediates the impact of exercise on mortality and 5-year changes in cognition. METHODS: In the Canadian Study of Health and Aging (n = 8,403, 60.7% women), cognitive states were defined as errors in the Modified Mini-Mental State Examination. Improvement and declines were modeled using a 4-parameter truncated Poisson distribution. RESULTS: Men and women showed similar levels of improvement or stabilization (34.1%, 95% CI = 32.1-35.9 in women and 30.2%, 95% CI = 28.2-32.4 in men). In unadjusted analysis, more men died (34%, 95% CI = 32.3-36.3) than did women (30.3%, 95% CI = 28.4-32.2). Higher education was beneficial for cognitive function in both sexes, but did not impact survival when other factors were considered. The effect of exercise differed by sex: women had a survival advantage compared with men, but men most benefited in cognitive functioning. CONCLUSIONS: Exercise is strongly associated with cognitive improvement and stabilization in men, and with better survival in women. In contrast to conventional approaches, our model allows us to analyze how different risk factors affect cognition to any degree, and simultaneously to assess their impact on survival.