But is this enough to recover your 5 lost years of brain cognition due to your stroke?
A Primary Care Agenda for Brain Health: A Scientific Statement From the American Heart Association
Abstract
A healthy brain is critical for living a longer and fuller life. The projected aging of the population, however, raises new challenges in maintaining quality of life. As we age, there is increasing compromise of neuronal activity that affects functions such as cognition, also making the brain vulnerable to disease. Once pathology-induced decline begins, few therapeutic options are available. Prevention is therefore paramount, and primary care can play a critical role. The purpose of this American Heart Association scientific statement is to provide an up-to-date summary for primary care providers in the assessment and modification of risk factors at the individual level that maintain brain health and prevent cognitive impairment. Building on the 2017 American Heart Association/American Stroke Association presidential advisory on defining brain health that included “Life’s Simple 7,” we describe here modifiable risk factors for cognitive decline, including depression, hypertension, physical inactivity, diabetes, obesity, hyperlipidemia, poor diet, smoking, social isolation, excessive alcohol use, sleep disorders, and hearing loss. These risk factors include behaviors, conditions, and lifestyles that can emerge before adulthood and can be routinely identified and managed by primary care clinicians.
The brain, through its capacity for cognition, is the organ that functions to register and record experiences. In youth, sound cognition is expected, but with aging, the increasingly vulnerable brain acquires injuries, and cognitive decline becomes more prevalent. As the average age of the US population grows, this age effect becomes of greater concern as the number of individuals with or at risk for mild cognitive impairment (MCI) and dementia grows.1 As of now, 1 in 5 Americans ≥65 years of age has MCI, and 1 in 7 has dementia2; by 2050, however, the number of Americans with dementia will triple.3 The importance of cognition was affirmed by the Affordable Care Act, which mandated coverage of an assessment of cognitive function as part of the annual wellness benefit for Medicare beneficiaries.4 The question arises, however, about what the health care community can do proactively to mitigate or forestall the onset of decline before it happens. Primary care is well suited to emphasize brain health as part of the goal of many preventive interventions. The purpose of this document is to summarize information that will help primary care providers optimize their effectiveness in maintaining brain health.
For clinicians and scientists, brain health can be approached along many structural, physiological, and epidemiological dimensions. Clinically, optimal brain health is the absence of cognitive impairment/dementia, stroke, and other brain diseases. Pathologically, optimal brain health is the absence of neurodegenerative, cerebrovascular, and comorbid diseases that interfere with everyday physical and cognitive functioning. Pragmatically, it is the preservation of neuronal function to meet the demands of everyday life, operationally defined in terms of the capacity to function adaptively in one’s environment. With aging come increasingly compromised neuronal activity and greater vulnerability to disease.5 The ability to think, solve problems, remember, perceive, and communicate is crucial to successful living; their loss can lead to helplessness and dependency. Once pathologically based decline begins, however, there are few therapeutic options to halt or slow the downward course.
Because of their central role in patient care and management, primary care providers are in a strategic position to identify and manage risk factors for cognitive decline. The goal is to identify and modify risk factors leading to brain injury before it happens. People with dementia experience lower quality of life,6 and caregivers, typically family members, experience high rates of psychological stress and physical ill health.7 Dementia is among the costliest medical conditions, shown to be more expensive in both direct and indirect costs than heart disease or cancer,8 with worldwide costs estimated at $818 billion in 2015.9 Delaying cognitive decline through primary care provider–instigated risk factor modification for even a small percentage of individuals would enable many more people to reach end of life without dementia and would have substantial benefits for patients, caregivers, and society.10
In 2017, the American Heart Association (AHA)/American Stroke Association issued a presidential advisory on defining brain health that included “Life’s Simple 7”11 as a follow-up to an earlier statement on the promotion of cardiovascular health12 (Figure). The goal of that document was to provide a model for operationally defining brain health in highly quantifiable terms and to suggest specific therapeutic targets for preventive intervention that included risk factor management and lifestyle changes. The purpose of the current statement is to update the evidence supporting that strategy and to emphasize the importance of dissemination and surveillance in the primary care setting. We acknowledge that the notion of brain health encompasses other functions such as mobility and emotional status, but they are interdependent with systems and conditions outside the brain. We chose cognition because it is uniquely dependent on the brain.
Figure. The American Heart Association’s Life’s Simple 7, as described by Lloyd-Jones et al12 and later Gorelick et al.11
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