RandallcHath Leisure Activities & the Risk of Dementia in the Elderly Essay Article Review Grading Neatness & Grammar ( supment both the article and your

RandallcHath Leisure Activities & the Risk of Dementia in the Elderly Essay Article Review Grading

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The
new england journal
of
medicine
original article
Leisure Activities and the Risk of Dementia
in the Elderly
Joe Verghese, M.D., Richard B. Lipton, M.D., Mindy J. Katz, M.P.H.,
Charles B. Hall, Ph.D., Carol A. Derby, Ph.D., Gail Kuslansky, Ph.D.,
Anne F. Ambrose, M.D., Martin Sliwinski, Ph.D., and Herman Buschke, M.D.
abstract
background
From the Einstein Aging Study (J.V., R.B.L.,
M.J.K., C.B.H., C.A.D., G.K., M.S., H.B.)
and the Departments of Neurology (J.V.,
R.B.L., C.B.H., C.A.D., G.K., H.B.), Epidemiology and Social Medicine (R.B.L., C.B.H.),
and Physical Medicine and Rehabilitation
(A.F.A.), Albert Einstein College of Medicine, Bronx, N.Y.; and the Department of
Psychology and the Center for Health and
Behavior, Syracuse University, Syracuse,
N.Y. (M.S.). Address reprint requests to
Dr. Verghese at the Einstein Aging Study,
Albert Einstein College of Medicine, 1165
Morris Park Ave., Bronx, NY 10461, or at
jverghes@aecom.yu.edu.
N Engl J Med 2003;348:2508-16.
Participation in leisure activities has been associated with a lower risk of dementia. It is
unclear whether increased participation in leisure activities lowers the risk of dementia
or participation in leisure activities declines during the preclinical phase of dementia.
methods
We examined the relation between leisure activities and the risk of dementia in a prospective cohort of 469 subjects older than 75 years of age who resided in the community and did not have dementia at base line. We examined the frequency of participation
in leisure activities at enrollment and derived cognitive-activity and physical-activity
scales in which the units of measure were activity-days per week. Cox proportional-hazards analysis was used to evaluate the risk of dementia according to the base-line level
of participation in leisure activities, with adjustment for age, sex, educational level, presence or absence of chronic medical illnesses, and base-line cognitive status.
Copyright © 2003 Massachusetts Medical Society.
results
Over a median follow-up period of 5.1 years, dementia developed in 124 subjects (Alzheimer’s disease in 61 subjects, vascular dementia in 30, mixed dementia in 25, and other types of dementia in 8). Among leisure activities, reading, playing board games, playing musical instruments, and dancing were associated with a reduced risk of dementia.
A one-point increment in the cognitive-activity score was significantly associated with
a reduced risk of dementia (hazard ratio, 0.93 [95 percent confidence interval, 0.90 to
0.97]), but a one-point increment in the physical-activity score was not (hazard ratio,
1.00). The association with the cognitive-activity score persisted after the exclusion of
the subjects with possible preclinical dementia at base line. Results were similar for Alzheimer’s disease and vascular dementia. In linear mixed models, increased participation
in cognitive activities at base line was associated with reduced rates of decline in memory.
conclusions
Participation in leisure activities is associated with a reduced risk of dementia, even after adjustment for base-line cognitive status and after the exclusion of subjects with possible preclinical dementia. Controlled trials are needed to assess the protective effect of
cognitive leisure activities on the risk of dementia.
2508
n engl j med 348;25
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june 19, 2003
The New England Journal of Medicine
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Copyright © 2003 Massachusetts Medical Society. All rights reserved.
leisure activities and dementia
he incidence of dementia increases with increasing age.1,2 Although
the prevention of dementia has emerged
as a major public health priority, there is a paucity
of potential preventive strategies.3-5 Identifying protective factors is essential to the formulation of effective interventions for dementia. Cross-sectional studies report associations between dementia and
reduced participation in leisure activities in midlife,
as well as between cognitive status and participation in leisure activities in old age.6,7 Katzman proposed that persons with higher educational levels
are more resistant to the effects of dementia as a
result of having greater cognitive reserve and increased complexity of neuronal synapses.8 Like education, participation in leisure activities may lower
the risk of dementia by improving cognitive reserve.9-15
In observational studies, elderly persons who
had participated to a greater extent in leisure activities had a lower risk of dementia than those who
had participated to a lesser extent.10-15 Although
these results suggest that leisure activities have a
protective role, an alternative explanation is possible. In most types of dementia, there is a long period of cognitive decline preceding diagnosis.16-18
Reduced participation in activities during this preclinical phase of dementia may be the consequence
and not the cause of cognitive decline. Resolution
of this issue requires a long period of observation
before diagnosis to enable researchers to disentangle the potential effects of preclinical dementia.
Base-line cognitive status, educational level, and
level of depression may confound the relation between leisure activities and dementia.10-15 Moreover, most studies have not assessed the associations between leisure activities and particular types
of dementia.10-14
The Bronx Aging Study provided us with the opportunity to study the influence of leisure activities on the risk of dementia over a long period19,20
while accounting for previously identified confounders. This community-based study has followed a cohort of persons who did not have dementia at base line, with the use of detailed clinical and
neuropsychological evaluations performed at intervals for up to 21 years.19,20 We examined the influence of individual and composite measures of
cognitive and physical leisure activities on the risk
of the development of dementia.
t
methods
study population
The study design and recruitment methods of the
Bronx Aging Study have been described previously.19,20 Briefly, the study enrolled English-speaking
subjects between 75 and 85 years of age who resided in the community. Criteria for exclusion included severe visual or hearing impairment and a previous diagnosis of idiopathic Parkinson’s disease,
liver disease, alcoholism, or known terminal illness.
Subjects were screened to rule out the presence of
dementia at base line and were included if they
made eight or fewer errors on the Blessed Information–Memory–Concentration test.19-21 This test has
a high test–retest reliability (0.86), and its results
correlate well with the stages of Alzheimer’s disease.22,23 At the inception of the study, the cohort
was middle-class, most subjects were white (91 percent), and the majority were female (64 percent).
Written informed consent was obtained at enrollment. The local institutional review board approved
the study protocol.
The study enrolled 488 subjects between 1980
and 1983. Subjects underwent detailed clinical and
neuropsychological evaluations at enrollment and
at follow-up visits every 12 to 18 months. The potential study period consisted of the 21-year period
from 1980 to 2001. We excluded 2 subjects without
documented leisure activities and 17 subjects who
moved or declined to return for follow-up. After
these subjects had been excluded, 469 subjects
(96.1 percent) were eligible. In 1992, 73 surviving
subjects were still having study visits in our current
project, the Einstein Aging Study.
clinical evaluation
During the study, subjects were interviewed with
the use of a structured medical-history questionnaire and were examined by study clinicians.19,20
Functional limitations on 10 basic and instrumental activities of daily living were rated on a 3-point
scale for each activity (range of total scores, 10 to
30 points), with 1 point indicating “no limitation,”
2 points indicating “does activity with difficulty,”
and 3 points indicating “unable.”19,20 A spouse or
family member accompanied most subjects or was
contacted for confirmation of the history.
neuropsychological evaluation
An extensive battery of neuropsychological tests
was administered at study visits.18-20 We examined
n engl j med 348;25
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june 19, 2003
The New England Journal of Medicine
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Copyright © 2003 Massachusetts Medical Society. All rights reserved.
2509
The
new england journal
performance on the Blessed Information–Memory–Concentration test (range of scores, 0 to 33),21
the verbal and performance IQ according to the
Wechsler Adult Intelligence Scale,24 the Fuld Object-Memory Evaluation (range of scores, 0 to 10),25
and the Zung depression scale (range of scores, 0 to
100).26 These tests were used to inform the diagnosis of dementia at case conferences.
leisure activities
At base line, subjects were interviewed regarding
participation in 6 cognitive activities (reading books
or newspapers, writing for pleasure, doing crossword puzzles, playing board games or cards, participating in organized group discussions, and playing musical instruments) and 11 physical activities
(playing tennis or golf, swimming, bicycling, dancing, participating in group exercises, playing team
games such as bowling, walking for exercise, climbing more than two flights of stairs, doing housework, and babysitting). Subjects reported the frequency of participation as “daily,” “several days per
week,” “once weekly,” “monthly,” “occasionally,” or
“never.” We recoded these responses to generate a
scale with one point corresponding to participation in one activity for one day per week. The units
of the scales are thus activity-days per week; the
scales were designed to be intuitively meaningful
to clinicians and elderly persons and to be useful in
the design of intervention studies or public health
recommendations. For each activity, subjects received seven points for daily participation; four
points for participating several days per week; one
point for participating once weekly; and zero points
for participating monthly, occasionally, or never. We
summed the activity-days for each activity to generate a cognitive-activity score, ranging from 0 to 42,
and a physical-activity score, ranging from 0 to 77.
The estimates of the overall level of participation were consistent with good test–retest reliability
for scores obtained on entry and at the next visit a
year later on the cognitive-activity scale (Spearman
r=0.518, P=0.001) and the physical-activity scales
(Spearman r=0.410, P=0.001). There was no direct
measurement of the time spent in activities, although participation was verified by family members or friends. The scores were not correlated with
age. Scores on the cognitive-activity scale correlated with scores on the Blessed test21 (Spearman
r=¡0.286, P=0.001), but not functional status
(Spearman r=¡0.042, P=0.77). Scores on the phys-
2510
n engl j med 348;25
of
medicine
ical-activity scale correlated with functional status
(Spearman r=¡0.293, P=0.001) but not with scores
on the Blessed test (Spearman r=¡0.021, P=0.65).21
diagnosis of dementia
At study visits, subjects in whom dementia was
suspected on the basis of the observations of members of the study staff, results of neuropsychological tests, or a worsening of the scores on the Blessed
test21 by four points or a total of more than seven
errors underwent a workup including computed tomographic scanning and blood tests.19,20 A diagnosis of dementia was assigned at case conferences
attended by study neurologists, a neuropsychologist, and a geriatric nurse clinician, according to the
criteria of the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) or, after 1986,
the revised third edition (DSM-III-R).27-29 Updated
criteria for the diagnosis of dementia and particular
types of dementia were introduced after the study
had begun.
To ensure uniformity of diagnosis, all cases were
discussed again at new diagnostic conferences held
in 2001 and involving a neurologist and a neuropsychologist who had not participated in diagnostic
conferences between 1980 and 1998.29 Dementia
was diagnosed according to the DSM-III-R criteria.28 Reduced participation in leisure activities was
used to assess functional decline, but the leisureactivity scales were not available to the raters assessing such decline. Disagreements between raters
were resolved by consensus after the case was presented to a second neurologist, with blinding maintained. Cases of dementia were classified according
to the criteria for probable or possible Alzheimer’s
disease published by the National Institutes of Neurological Disorders and Stroke and the Alzheimer’s
Disease and Related Disorders Association30 and
the criteria for probable, possible, or mixed vascular dementia published by the Alzheimer’s Disease
Research Centers of California.31
statistical analysis
Continuous variables were compared with use of
either an independent-samples t-test or the Mann–
Whitney U test, and categorical variables were compared with use of the Pearson chi-square test.32 In
primary analyses, we studied the association between cognitive and physical activities and the risk
of dementia and specific types of dementia using
Cox proportional-hazards regression analysis to es-
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june 19 , 2003
The New England Journal of Medicine
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Copyright © 2003 Massachusetts Medical Society. All rights reserved.
leisure activities and dementia
timate hazard ratios, with 95 percent confidence intervals.33 The time to an event was defined as the
time from enrollment to the date of a diagnosis of
dementia or to the final contact or visit for subjects without dementia. All multivariate models reported include the following covariates unless otherwise specified: age at enrollment, sex, educational
level (high school or less vs. college-level education), presence or absence of chronic medical illnesses, and base-line scores on the Blessed test.
Presence of the following self-reported chronic
medical illnesses was individually entered in the
models: cardiac disease (angina, previous myocardial infarction, or cardiac failure), hypertension, diabetes mellitus, stroke, depression, and hypothyroidism. We also divided the study cohort into thirds
on the basis of their scores on the two activity scales
and determined the risk of dementia according to
these groups. We examined the role of individual
leisure activities by comparing subjects who participated in an activity several days or more per week
(frequent participation) with subjects who participated weekly or less frequently (rare participation)
and, in the full models, adjusted for participation in
other leisure activities.
In secondary analyses, we examined the influence of base-line cognitive status and possible preclinical dementia. First, we sequentially excluded
from the full models subjects in whom dementia developed during the first two, four, seven, and nine
years of follow-up in order to avoid confounding by
a possible influence of preclinical dementia on participation in leisure activities. Second, we used linear
mixed models controlled for age, sex, and educational level to assess the relation between cognitive
activities and base-line cognitive status and the annual rate of change in cognitive status.34 We analyzed verbal IQ as well as specific cognitive domains,
including episodic memory (with the Buschke Selective Reminding test [range of scores, 0 to 72, with
lower scores indicating worse memory]35 and the
Fuld Object-Memory Evaluation25) and executive
function (with the Digit–Symbol Substitution subtest of the Wechsler Adult Intelligence Scale [range
of scores, 0 to 90, with lower scores indicating worse
cognition]).24 Each model included terms for the
cognitive-activity score, time, and the interaction
between the two. The assumptions of the models
were examined analytically and graphically and were
adequately met.
n engl j med 348;25
results
demographic characteristics
During 2702 person-years of follow-up (median follow-up, 5.1 years), dementia developed in 124 subjects (Alzheimer’s disease in 61, vascular dementia
in 30, mixed dementia in 25, and other types of dementia in 8). By the end of the study period, 361 subjects had died, 88 subjects had dropped out (mean
[±SD] follow-up, 6.6±4.9 years), and 20 subjects
were still active. When the cohort was divided into
thirds according to the cognitive-activity score or
the physical-activity score, no significant differences
in the length of follow-up were found among these
subgroups.
On average, subjects in whom dementia developed were older, had lower levels of education, and
had significantly lower scores on the cognitiveactivity scale, but not on the physical-activity scale,
than subjects in whom dementia did not develop
(Table 1). Although their scores on neuropsychological tests were in the normal range (Table 1), subjects in whom dementia later developed had poorer
cognition on the Blessed test (P=0.001)21 and a lower base-line performance IQ (P=0.07).24 The frequency of chronic medical illnesses did not differ
significantly between subjects in whom dementia
developed and those in whom it did not. Nineteen
subjects were receiving antidepressants at enrollment. Cognitive-activity scores were inversely correlated with the Zung depression scale26 (Spearman
r = ¡0.215, P
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