1. cognition and mood Exercise as an intervention across
Joe Verghese, MBBS, MS
Albert Einstein College of Medicine
Bronx, NY
Disclosure 1: Funding received from National Institutes On Aging (grants PO1 AGO3949 and RO1 AGO25119)

2. Disclosure 2: The speaker has not received any funding from these companies (not even a cup of coffee!)

3. Exercise Good for the brain? Good for mood? Which activities?
How much?
How do they work?

4. Strength of evidence? Mental exercise Physical exercise
Social activities
Observational Vs. RCT

5. Fratiglioni, Lancet Neurol 2004

6. Bronx Aging Study Inception: 1980-1983 488 volunteers Age 75-85
Community living
90% Caucasian
65% women
No dementia
Katzman R, Ann Neurol 1989, Verghese J, NEJM 2003

7. 469 nondemented subjects Study period: 1980-2001 124 Dementia
Clinical, neuropsychological evaluations at entry and
at mo follow-up visits
Study period:
124 Dementia
Vascular dementia
25 Mixed dementia

8. Cognitive

9. Physical

10. Leisure activity scales
Cognitive activity scale (0-42)
Physical activity scale (0-77)
Activity days X X X X X X
7 : almost daily X X X X
4: several days X
1: once weekly
0: < weekly or never

11. Hazard ratio (95% CI) Cognitive Physical
Dementia ( ) ( )
Vascular ( ) ( )
Mixed ( ) ( )
aMCI ( ) ( )
VCI ( ) ( )
Verghese NEJM 2003, Neurology 2006

12. Walking better baseline cognition
Honolulu-Asia study
2257 men 71-93y
Vs. 2mi/day
<0.25: HR 1.77
0.25 to 1: HR 1.71
Abbott, et al. JAMA 2004
Nurses Health Study
18,766 women 70-81y
Walking better baseline cognition
Physical activity ↓ cognitive decline
Weuve J, et al. JAMA 2004
Bronx Aging study
Walking HR 0.67 ( )

13. Dancing and risk of dementia Adjusted Hazard Ratio 0.24 (0.06-0.99)
Verghese J, N Engl J Med 2003

14. Dancers have better gait but not cognition
Dancers Non-dancers p
(24) (84)
Blessed test
FCSRT
Block design
Digit span
Digit Symbol
Verbal Fluency
Trail Making B
Matched by age, sex, and education.
Dancers have better gait but not cognition
Verghese J, J Am Geriatr Soc 2006

15. Life-p
Table c Cognitive tests at baseline and 12-mo in the entire cohort
Baseline
12 mo
Cognitive Test
Mean SD
DSST
47.0
12.3
46.6
14.2
Rey Short
6.9
3.0
7.7
2.7
Rey Long
6.1
3.3
3.1
Rey Inference
3.7
1.6
3.9
1.4
3MS
90.6
6.4
91.0
6.5
Stroop
40.8
22.3
39.7
22.0

16. ACTIVE trial Memory Mnemonics, list recall N =703 Reasoning
Problem solving
N = 699
Processing speed
Visual search
N = 702
Control
N = 698
Ball, K. JAMA 2002

17. Exercise and mood Two meta-analyses of RCT of exercise and depression.
Lawlor & Hopker, BMJ 2001
Stathopoulou G., et al. Clinical Psychology 2006

18. Lawlor & Hopker. BMJ 2001;322:763

19. RCT: PHYSICAL EXERCISE Vs. No INTERVENTION
Heterogenity length of follow up and publication type. Not allocation, setting, baseline depression, exercise type
Pooled standardized mean difference in effect size:
-1.1 (95% CI -1.5 to -0.6).
Lawlor & Hopker. BMJ 2001

20. RCT: EFFECT OF PHYSICAL EXERCISE Vs. COGNITIVE THERAPY
Pooled standardized mean difference in effect size:
-0.3 (95% CI -0.7 to 0.1)
Lawlor & Hopker. BMJ 2001

21. RCT with non-active comparison
Stathopoulou, G., et al. Clinical Psychology: Science and Practice 2006, 13, 179–193.
RCT with non-active comparison
(wait list, placebo, low level exercise, health education)
Depression secondary to medical illness excluded

22. Mean overall effect size: 1.39 (95% 0.89 to 1.82)

23. ↓ at 26 mo N Age Intervention Effect Ref 32 70
Resistance training 3/wk
Health seminar 2/wk No
Singh, et al.
1997 30
72.5
Walk x 40 min - 3/wk
Chat x 1h - 2/wk
Wait list control
Social: NO
Wait list: YES
McNeill, et al.
1991
71.3
Weight lifting 10 wk followed by unsupervised exercise 10 wk
Lectures x 10 wk
Beck DI
↓ at 26 mo
Singh, et al. 2005
156 57
Exercise 3/wk x 16wk
Antidepressant
Combination
No difference
20% drop out
Blumenthal, et al. 1999 86 63
.Weight/stretch x 10wk
Health Education
p = 0.05
Mather, et al. 2002

24. Shakespeare Wm. As you like it. Act II, Scene VII
All the world's a stage, And all the men and women merely players; They have their exits and their entrances; and one man in his time plays many parts, His acts being seven ages……………. Last scene of all, that ends this strange eventful history, Is second childishness and mere oblivion; Sans teeth, sans eyes, sans taste, sans everything."
Shakespeare Wm. As you like it. Act II, Scene VII

25. How much?

26. 1 4 Cognitive Activity Scale (0-42)
Dementia Hazard ratio 0.93 (7% risk reduction) 1 4

27. Low levels of participation!
73 urban elderly
Mean age 80.5 y
90% women
Mean activity scores
Ambrose AF, Poster A77: AGS 2005

28. Mechanisms Cardiac fitness Neurobiological benefits of exercise:
Serotonin, endorphin, neurotrophic factors
Stress
Improved sleep patterns
Cognitive reserve

29. Brain effects 6 month RCT 59 sedentary elderly
Aerobic exercise group vs. stretching/toning
Colcombe et al. J Gerontol A Biol Sci Med Sci2006

30. 11 subjects
33y (21-45)
Aerobic 4/wk x 11
Pereira As, et a. PNAS 2007

31. Can leisure activities be bad for you?
Daily TV viewing 1.32 (1.08 – 2.62)
Social activities (0.68 – 0.98)
Physical activities (0.89 – 1.38)
Intellectual activities 0.84 (0.72 – 0.98)
Adjusted for age, gender, education, and income.
Lindstrom, et al. Brain & Cognition, 2005

32. Exercise Challenges 1 Small studies, volunteer populations
Brief follow-up.
Effective short term but long term?
Give up easily: 20% drop out rate
Less active at baseline
Poor maintenance behaviors: dyads

33. Exercise Challenges 2 Aerobic vs. Anaerobic
Physical, Cognitive, Social, or all three?
Cognitive domain specific
Biomarkers (track effect and change)