Editor's Note: Commentary based on Ngandu T, Lehtisalo J, Solomon A, et al. A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial. Lancet 2015:1-9.

Background

Cardiovascular disease (CVD) and CVD risk factors are associated with the development of dementia;^1,2 therefore, cardiologists caring for older adults frequently encounter patients with comorbid cognitive decline or dementia. Similar to the prevention and management of other chronic diseases, dementia may be best addressed in a multidisciplinary, team setting.

Methods

The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) trial³ was a population-based, randomized, controlled, clinical trial undertaken across six centers in Finland that compared a two-year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring to a control group that received standard care and general health advice to assess the prevention of cognitive decline in at-risk older adults.

Patients were eligible to be included in the study if they were between ages 60 and 77 years old, with a Cardiovascular Risk Factors, Aging and Dementia (CAIDE) score of 6 points or higher (based on age, sex, education, systolic blood pressure, body mass index, total cholesterol, physical inactivity; range 0-15 points). The predominant exclusion criteria were a prior diagnosis of dementia, suspected dementia after study visit, mini mental state examination score of <20 points, disorders affecting safe engagement in the intervention, and severe loss of vision, hearing, or communicative ability.

A total of 1,190 patients were randomized (intervention group, n = 591; control group, n = 599) using a computer-generated blocked randomization pattern with a block size of 4 in a 1:1 fashion. Double blinding was "pursued as much as possible."

Patients in the treatment arm were encouraged to eat a diet rich in fruits and vegetables, whole grain cereal products, and low fat meat and milk products; use vegetable margarine and rapeseed oil instead of butter; consume fish at least twice per week; and limit sucrose intake to <50 g per day. Exercise training was performed under the guidance of a physiotherapist and included strength training one to three times per week and aerobic training three to five times per week. Cognitive training consisted of 10-15 minutes of daily computer exercises designed to test executive processes, working memory, episodic memory, and mental speed. Metabolic and vascular risk factors were measured (blood pressure, weight, body mass index, and hip and waist circumference) and study physicians gave lifestyle recommendations based on these measurements. Patients were encouraged to contact their primary care physicians if study personnel believed medications should be prescribed.

The primary outcome was a change in cognitive performance measured with a neuropsychological test battery (NTB) total score (calculated as Z scores and standard deviation [SD]; higher Z scores indicating improved performance). Secondary outcomes include NTB domain Z scores for executive functioning, processing speed, and memory. The primary results were reported as a modified intent-to-treat analysis.

Results

The intervention and control groups were similar at baseline.

Primary Outcome

After two years of follow-up, the intervention group had a 25% higher NTB total Z-score compared to the control group (Z-score 0.20 [SD 0.51] and 0.16 [SD 0.51], respectively). In a post-hoc analysis, the odds ratio (OR) for risk of overall cognitive decline for the control group compared to the intervention group from baseline to two years was 1.31 (95% confidence interval [CI]: 1.01-1.71; p = 0.04).

Secondary Outcomes

In a post-hoc analysis, the OR in the control group compared to the intervention group for decreased memory over the two-year study period was 1.23 (95% CI: 0.95-1.60, p = 0.12), Similarly, the OR for decreased executive function was 1.29 (95% CI: 1.02-1.64; p = 0.04) while the OR for decreased processing speed was 1.35 (95% CI: 1.06-1.71; p = 0.01).

Conclusion

A multi-faceted intervention that simultaneously targeted lifestyle factors, cognitive training, and CVD risk factor management improved the primary outcome of preventing overall cognitive decline, as noted by an increased NTB total Z score compared to the control group. An improvement in NTB executive functioning Z score and NTB processing speed score was also demonstrated in the intervention arm with no improvement in the NTB memory score.

Commentary/Perspective

Although cognitive decline and dementia are rarely discussed in the cardiologists' office, they play a significant role in the care of many older adults with CVD, as the two disease processes share common risk factors. Because cardiologists are likely to see patients who are at risk for developing dementia later in life, they are well positioned to advise patients regarding the beneficial effects of a healthy diet and regular exercise, not only for CVD management, but also for preservation of cognitive function.

Cardiologists are also well positioned to ensure metabolic and vascular risk factors, such as obesity and high blood pressure, are appropriately addressed. The cardiologist with a geriatric focus has an even higher potential to be an important member of these patients' medical home, working closely with geriatricians, neurologists, and primary care doctors to provide high-quality care for a population often plagued by multiple chronic conditions.

References

1. Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C. Potential for primary prevention of Alzheimer's disease: an analysis of population-based data. Lancet Neurol 2014;13:788-94.
2. Gorelick PB, Scuteri A, Black SE, et al. Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:2672-713.
3. Ngandu T, Lehtisalo J, Solomon A, et al. A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial. Lancet 2015:1-9.

Keywords: Adult, Aged, Blood Pressure, Body Mass Index, Body Weight, Cardiovascular Diseases, Cholesterol, Chronic Disease, Cognition, Dementia, Diet, Executive Function, Exercise, Hypertension, Intervention Studies, Life Style, Memory, Episodic, Memory, Short-Term, Neuropsychological Tests, Obesity, Patient-Centered Care, Physical Therapists, Physicians, Primary Care, Resistance Training, Risk Factors, Sucrose, Waist Circumference

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