Advancing Cognitive Well-Being Through the Healthy Brain Initiative Road Map

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode, we examine the nation's newest roadmap for better brain health.

DR. LISA MCGUIRE:
It's really trying to look at the existing structure and infrastructure you have, to make some modification within your existing infrastructure that truly can make a difference for the health, the wellbeing, and maintaining the independence of the people residing in your state or territory.

MOLLY FRENCH:
There's a lot of that can be done within health departments' existing resources, and our chapters are there ready to be partners in getting health departments going on this journey.

DR. JEWEL MULLEN:
I'm not really asking you to do anything new. I'm just asking you to broaden your lens as you consider the type of public health efforts you undertake and the populations that they touch.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we discuss the most pressing public health issues facing our states and territories and explore what health departments are doing to improve the condition of our country's most vulnerable populations.

Today, we're covering the release of the third Healthy Brain Initiative Road Map, a national strategy to help public health professionals improve their state programs to address a growing number of Americans with Alzheimer's and other dementias. Recently, a well known American, the nation's first female Supreme Court justice Sandra Day O'Connor, announced she too is battling dementia. Whether famous or not, the list of people struggling against the condition is projected to get longer.

Our guests know the work that lies ahead. Each is a strong advocate of the roadmap, each is a champion for the cause of better brain health. All three encourage healthy aging for a burgeoning senior population.

Dr. Jewel Mullen was ASTHO's board president in 2015 when she made this cause her challenge to the states and territories. Molly French leads public health for the Alzheimer's Association and helped write the newest roadmap. We'll hear from them later.

First, we are talking with the roadmap's co-author Dr. Lisa McGuire, the lead for the Alzheimer's Disease and Healthy Aging program at the Centers for Disease Control and Prevention. We begin with Dr. McGuire's report on the outlook for America's aging population.

MCGUIRE:
So, currently in the U.S.—so that's in 2018—we know that almost 6 million people have Alzheimer's disease or some other type of related dementia, at least 6 million. We expect—based on some recent CDC statistics—that by 2060, we expect that there will be almost 14 million people affected. We expect to see a nearly a three-fold increase in the number of people who have Alzheimer's disease or related dementias.

One of the challenges with brain health as we're moving forward is one of the biggest predictors or risk factors to developing Alzheimer's disease or related dementia is increasing chronological age. So, we see as the baby boomers are getting older, that we expect in the future there'll be more people who have Alzheimer's or related dementia, unless we are able to find a cure or a treatment to the disease.

JOHNSON:
So, that's basically a population-getting-older situation.

MCGUIRE:
Correct. So, one of the main reasons we see the increased numbers is that people are living longer—they're not dying as early as they did historically from other chronic conditions; and we see that they are living long enough to develop some type of Alzheimer's disease or related dementia.

We know, of those people who do have Alzheimer's or related dementia, about 95% of them also have another chronic health conditions. So, we still have a lot of work to do when we're talking about chronic disease prevention and management.

JOHNSON:
Is there any other factor that contributes to the disease or a person getting it?

MCGUIRE:
Well, at this point, we do not know the exact causes of Alzheimer's disease or related dementias; and the science is evolving each and every day as to what preventative measures people can do to reduce their risk. Some of the early evidence suggests that managing your blood pressure as a middle-aged and younger adult may reduce your risk of developing Alzheimer's or dementia in your later years; and we do know that those precautions that people take to manage their cardiovascular risk factors do tend to see positive outcomes with their brains.

JOHNSON:
The CDC materials on this topic pose a question I would like to have you answer for our listeners; and the question is, are communities ready to respond to a larger population of older people with dementia?

MCGUIRE:
Are communities ready? It really depends on the community.

Some communities have been planning and looking at an aging population in their areas and planning for that, which also includes those people who do have Alzheimer's or some other types of dementia. So, it really depends on the community. Some are more advanced, and others are planning and have state plans and are working towards becoming ready.

JOHNSON:
Your team has launched a third edition of the Healthy Brain Initiative Road Map covering 2018 through 2023, and we assume that it's meant to help communities get ready. So, can you explain for us what the roadmap is first, and then what's new in this latest addition of the strategy?

MCGUIRE:
Right. The new roadmap is really helping states and local public health agencies and their partners really think quickly and strategically to help prepare their communities for this increasing population of people who do have Alzheimer's or related dementias.

So, what this roadmap did is we examined the interventions and the outcomes from our previous two roadmaps to see where the science is, where the needs are, where are the demands are, and what are the most important things that need to be done over the next five years for states and local public health departments.

So, based on this review and process with over 150 leaders in the field, we developed an action agenda of 25 activities that public health leaders can take to really think about strengthening their public health capacity in this area that is also consistent with the essential services of public health, which will make it hopefully more easy for the states and the local health departments to integrate these action items into their existing infrastructure.

JOHNSON:
And you've got those organized into four distinct categories. I thought it might be useful to go through each one, starting with the section titled Educate and Empower.

MCGUIRE:
So, the first one of those services that's included in the roadmap is Educate and Empower the Nation. And the type of activities that are included there, is there are seven different types of activities that really are trying to increase awareness and increase the conversation about Alzheimer's and dementia, and to really get the messaging out to people who either may be having symptoms of the disease process or to their caregivers.

JOHNSON:
How about the next category—Develop Policies and Mobilize Partnerships.

MCGUIRE:
So, that section—Develop Policies and Mobilize Partnerships—has six action items associated with it. And really it's thinking more at that systemic level, which is what public health does, and thinking about how to develop the systems and the infrastructure that's going to improve the health and wellbeing of those people who do have Alzheimer's or related dementia and their caregivers.

JOHNSON:
Then comes A Sure, A Competent workforce. Talk about that one.

MCGUIRE:
So, for A Sure, A Competent workforce, the items that are included in these priority items—there are seven of them as well. And really this is making sure that healthcare providers—and this is a whole variety of the whole gamut of healthcare providers—have the information, the tools, and resources that they need to interact and to work with an aging population, especially those that have Alzheimer's disease or dementia.

So, this domain is really looking at developing people as they're growing into the workforce—so, in other words, educating future healthcare professionals—as well as providing training for those who are in their healthcare years as well as to have some continuing education to help those individuals who are currently in the workforce to stay current and have the information that they need.

JOHNSON:
And then, the last category is Monitor and Evaluate.

MCGUIRE:
One of the key functions of public health is to be able to monitor and to know what's going on in your state or your locale; and so, in other words, to collect that data and have that information so you know the number of people who might be experiencing some memory loss or confusion and are concerned about it, and so you also are aware of the number of caregivers you have in your area and the types of people that they are caring for.

So, really this section of the roadmap has five items that's really getting people to look at their communities and the data sources that they have and to help collect data that's going to help them provide information and data that they can act upon in their communities.

JOHNSON:
Now, if I'm a public health professional in a state or territory, I've been assigned to take on this issue, and I'm looking at this sheet of tactics and these four categories. Is there more detail under each one of these available to me to help me really know what I should do to focus on just getting down to the brass tacks of this effort?

MCGUIRE:
Yeah. So, that's one of the things that the new roadmap does that the previous roadmaps did not do. It really helps a person that's wanting to implement the action items from the roadmap, provides them a series of steps and things to think through. Because we know that each state, each locale has different resources, different structures; and to be able to respond to this growing population of their constituents, they need to do it based on their existing resource structure and existing programs.

And so, that's one of the nice things that this new roadmap does is helps people identify where can you start. If you have limited resources, here are some places for us to start. So, for example, in our 25 action items, we have identified 10 of those so that if you need a place to start, these would be 10 that are ripe and would make an impact in your area.

JOHNSON:
So, those would be the equivalent of low-hanging fruit?

MCGUIRE:
Right. They're ripe for implementation, is the term we're using.

JOHNSON:
That's better than low-hanging fruit.

The CDC has a companion roadmap for Indian country also coming out soon. Can you tell us when that one is due and how it's tailored to the needs and concerns of that population?

MCGUIRE:
So, the new Indian country roadmap is a new endeavor for us, and we are hoping to release that in very early 2019. But what we've done with that Indian country roadmap is we've reached out to various tribes, tribal organizations, and native leaders to talk with them about their needs and what they're experiencing and seeing in Indian country. And so, we've modified these 25 action items and another list that's tailored to specific tribal Indian.

JOHNSON:
Are you able to give us a snapshot or a brief overview of what sorts of things might be different?

MCGUIRE:
Well, some of the challenges that we see and we've learned about when we were speaking with tribal leaders is there's a lot of variability between the tribes. So, just because you are a federally recognized tribe in the United States, or even a tribe that's not recognized—some are very small and very resource-poor, whereas others are large and the size of many states in New England, and do have more resources, which means more care available to them as well. And then, we have people who are urban, who are American Indians as well.

JOHNSON:
As we noted earlier, and you mentioned that at least once in one of your comments here, the new road map is the third edition of the plan; so, are there any results to report from the previous two iterations?

MCGUIRE:
Well, one of the things that we are very proud of that has resulted is we have been able to develop a national surveillance system related to cognitive decline and also to caregiving—so, really two separate national surveillance systems.

So, through CDC's behavioral risk factor surveillance system, the Alzheimer's Disease and Healthy Aging program supports two modules on that surveillance system. One is cognitive decline; so people are evaluating their memory and they're evaluating if they notice changes in their memory that have gotten worse over the past year. They're also telling us if they've had to curtail or change some of their daily activities because of their memory performance.

So, we have this information available for all states and territories that administered the module, and it gives public health professionals a glimpse of what might be coming in their states. So, in other words, we know that some people who report these memory concerns go on to develop Alzheimer's disease, but others do not.

We also have similar information about caregiving; so, we know the number of people in your state who are caregivers, we know how long they've been caregivers, how many hours a week they are caregivers, who they are caring for—their mom, their mother-in-law, a neighbor, or a spouse—and we also know the health condition of that person.

So, one of the things that we're very proud of is we now have information that are available. And we at CDC have taken that information and developed state-specific infographics, and we have developed scientific publications as well. So, we have the data available in a variety of different formats that is usable and can be put in the hands of people to really impact activities in their states.

JOHNSON:
And all of that was a key outcome of the previous efforts?

MCGUIRE:
It was a key outcome of the previous roadmaps.

JOHNSON:
The roadmap seems to seek to prepare health providers for this coming wave of new patients; but doesn't it also encourage prevention?

MCGUIRE:
It does. And as I mentioned previously, prevention and the science around it is evolving. The National Institute on Aging and other federal organizations are funding scientific research to truly understand what the cause of Alzheimer's and related dementias are. how you can treat them. And once we understand that, that will also help us inform the prevention or the ways to slow the disease course and process.

But what the roadmap is encouraging is that, for example, physicians and the public is aware of the best available scientific evidence on brain health so we can communicate that information, such as blood pressure management, such as living a healthy lifestyle across the lifespan.

JOHNSON:
Now, I assume most, if not all states, are doing something in this area; but for those not yet focused on the issue, how would you close up this conversation? What would the call to action be?

MCGUIRE:
Well, the call to action for states, I think, is to first look at their Alzheimer's disease plan if they have one existing or, if they don't, if they have a state aging plan, to look and see if there are components of like, for instance, your aging plan that's dealing with brain health and issues related to those people who are caring for someone who may have Alzheimer's disease or related dementia.

So, it's really trying to look at the existing structure and infrastructure you have to make some modifications within your existing infrastructure that truly can make a difference for the health, the wellbeing, and maintaining the independence of the people residing in your state or territory.

JOHNSON:
If public health professionals want more information, where do they go?

MCGUIRE:
Cdc.gov/aging/roadmap.

JOHNSON:
The roadmap seeks to make it easier for public health leaders to engage on the issue of brain health, but each of our guests understands the strain on resources at every level. Molly French helped write the roadmap from her position as public health director for the Alzheimer's Association, an organization whose 78 chapters stand ready to assist with the hard work yet to come.

FRENCH:
Through our nationwide chapter network, we focused on, you know, about 10 that are really ripe for action, where we know that there's resources that are available that public health departments can use to make this quicker and easier and more efficient to get started; as well as where we have heard that there's initial interest from public health leaders, because those are the actions that we've seen start up and get going across the country because they're feasible and doable at this time.

JOHNSON:
Let's talk about that network of chapters that are part of the Alzheimer's Association. How do they support the work of the public sector practitioners on this front?

FRENCH:
Our chapters reach out and try and build relationships with the state public health departments to really be a ready resource and a partner. Some state public health leaders have chosen to partner with our chapters, for example, so that they can help the different resources that the association has, for example, in educating the public about ways to reduce risk for cognitive decline and promote cognitive functioning as they age. Public health departments like New Mexico have used that framework in terms of getting that information out to the public. And it also reinforces and refreshes healthy behavior initiatives that they have.

Our chapters also do a lot of work with a wide variety of different stakeholders in terms of developing or updating state Alzheimer's plans, as well as helping those plans get implemented. So, the chapters can be important linkage bringing in the public health department into those state Alzheimer's plan task forces, which often are really missing the capabilities and the strategies and the data that public health has.

So, those are two ways that our nationwide network of chapters can really be great partners for state and local public health.

JOHNSON:
I suspect that you are anxious to offer that help; so, if a state isn't tapping into that resource, you would encourage them to do so.

FRENCH:
I certainly would encourage them to reach out to our local chapter. And you can also reach out here to our national office—we kind of maintain that bird's-eye view of what's going on in different states. And in fact, our website, alz.org/professionals/public-health, has a lot of new resources to help states and local public health departments get going. It has a lot of the data, including from the behavioral risk factor surveillance system, to help practitioners make the case for taking action on Alzheimer's.

We have a lot of different examples with different states, what they're doing to implement the roadmap. And we also, you know, people can go in and search for those resources that can make it easy to implement actions in the roadmap. For example, the National Institute of Health has this great campaign on hypertension, which certainly relates to stroke and cardiovascular disease, but also in particular vascular dementia, too. NIH has a beautiful campaign called Mind Your Risk and people can go to the website, find it, and then learn how to get those resources into the community, which enables them to promote both heart health and brain health.

JOHNSON:
What's that website address again for the site you operate?

FRENCH:
Yes, it is alz.org/professionals/public-health.

JOHNSON:
Okay. We'll include that link in the show notes, too.

With the number of Alzheimer's cases are expected to grow so much over the next 30 years, it would seem we really don't have much time to waste. 30 years seems like forever, but really when you're talking about this sort of change outlined on the roadmap, it could take a while to get that done. Do you agree that we need to get on this?

FRENCH:
I agree wholeheartedly. We'd love to see every state implementing all 25 actions in the new roadmap.

People are really hungry in particular for information about Alzheimer's and other dementia. There's a lot of misconceptions out there about what is normal aging, what are the normal changes that the brain goes through—just as any organ as we age—and which ones really merit at a discussion with the doctor. You know, public health departments are such a trusted source of information for consumers. That's an easy way for public health departments to get started, helping the public separate fact from fiction.

Another really important reason for public health leaders to get started—we know the trajectory of Alzheimer's is growing in part because of the baby boomers, and the growing prevalence is greatly impacting employers as well as employees, particularly with retiree plans, but certainly with state Medicaid costs. And that's another key reason for public health departments to bring in their expertise, particularly on chronic disease management since we know 95% of people living with Alzheimer's have one or more chronic conditions.

And the third reason is just that—no one listening to the podcast can go a day or two without hearing a new story, or you get some information from somebody saying, "Oh, coconut oil is the best way prevent Alzheimer's, and take a couple tablespoons each day." There's a lot of information and commercial interests in terms of meeting people's hunger for figuring out, "How can I avoid developing Alzheimer's and other dementias myself?" And that's a tremendous way that public health departments can start making a difference is really getting people focused on those modifiable risk factors and making those lifestyle changes to better protect their overall health and their brain health.

JOHNSON:
Wrapping up, what can you tell public health professionals listening to this podcast that will give them the energy they need to engage in this cause?

FRENCH:
I would say you don't have to take on the whole cause at once. Find something to get going, and in fact it can bring a lot of benefits to assisting public health work. For example, because of the linkages with smoking—smoking is a risk factor for dementia. We know a lot of public health departments are already doing a lot in terms of tobacco prevention and control, they're having challenges in terms of those lifelong smokers. You know, pulling into your department, you know, information about Alzheimer's and dementia is—and, for example, the linkages with current smoking—can be a new way to motivate those lifelong smokers to start a quit attempt.

We encourage, you know, not taking on a whole lot, but there's a lot that can be done within health departments' existing resources, and our chapters are there ready to be partners in getting health departments going on this journey.

JOHNSON:
You don't have to do it alone.

FRENCH:
You don't have to do alone. And there are a tremendous number, a growing number of different examples from other public health agencies across the country that are readily adaptable to a wide variety of situations. They also don't have to figure things out from scratch.

JOHNSON:
A few years ago, ASTHO's board president made the roadmap for president's challenge. Dr. Jewel Mullen was Connecticut's public health commissioner at the time. Now, she's the associate dean for health equity within the Dell Medical School at the University of Texas in Austin.

MULLEN:
Having healthy aging become my presidential priority was logical for me for a number of reasons. I'm an internal medicine physician, and because of that I've taken care of adults from adolescence to the latest stages of life; and it's been apparent to me as both a medical practitioner and a public health practitioner that oftentimes our attention, focus, and priorities end up directed towards people at younger life stages rather than older ones.

So, the opportunity to have a platform gave me a chance to hold myself and my peers accountable to our commitment to a life course approach to public health and wellbeing that didn't stop at the age of 65 or some other number, but that actually followed through people's life course. That, to me, meant pausing so that we could pay attention to the needs and wellbeing of older adults.

JOHNSON:
What did you ask your colleagues to do four years ago?

MULLEN:
I asked them to work with the idea of older adults representing a segment of our population and to think about them in a broad way, understanding first that there's no single definition or profile of aging or seniors, because the conditions and needs of older people change throughout the multiple decades after the age of 65 that many of them live. And then, I asked my colleagues to consider doing just what they do for any other population, which is to really think about the discrete needs for older adults across those ages, across those many years of later life.

So, my message in part was, "I'm not really asking you to do anything new. I'm just asking you to broaden your lens as you consider the type of public health efforts to undertake and the populations that they touch." A lot of the work we do in public health that focuses on prevention or establishing policies and systems to support people are efforts that maybe need to be tweaked to ensure older adults' needs are taken into account. But many of them are not new—when we're talking about, for example, addressing the burden of chronic disease.

JOHNSON:
38 states got on board with your plan. You had to be pleased with that.

MULLEN:
I was very pleased; and I have to say that I was more focused on getting into people's hearts and minds and getting them to think about their approach whether or not they could see themselves signing on with a pledge. And the reason for that is, as we all know, there are so many demands on public health officials—there are the issues that they deal with every day at the same time that we're always standing ready to respond to an acute problem. So, the last thing I wanted to do with my colleagues was to tell them I was giving them something else that they needed to do.

The other reason that I was pleased was that I see an important role for the state health official to be that way of building the leadership and capability of his or her staff. So, just calling attention to an issue like healthy aging did not require that the health official suddenly create a new portfolio of work coming out of the commissioner or secretary office. Rather, it created an opportunity for that senior official to support the work of staff in their agency who may have been working on issues related to cognition, or chronic disease prevention and control, or injury prevention, or community services and support.

So, I really wanted my president's challenge to be one which lived beyond the year of my presidency.

JOHNSON:
Do you think that's happened?

MULLEN:
I do. And I have to say, I felt especially fortunate because, just by coincidence, I lead this challenge in the year that coincided with the National White House Conference on Aging and the anniversary of the Older Americans Act. So, there was a lot of other national attention and there were many other convenings unfolding coinciding with the work of my challenge.

Many of us who were involved in those multiple efforts said to ourselves, and stated publicly, that we did not want 2015 to be a moment in time, but to be thought of as the next beginning of something that needed to continue with people mobilizing around older people and their needs. And I do believe that that's happened, not just because of my challenge, but that the work that we did across the states has also been bolstered by other efforts.

JOHNSON:
As you look at this new roadmap—now on the street available to all public health and people who work around this space—and as a former leader in the state health realm, what would you hope the reaction to this new roadmap would be among your former colleagues?

MULLEN:
I hope that most of them, if not all of them, look and say, "This is just so logical. We need to do this." And that they will, rather than say, "Here's another stream of work," that they'll take the opportunity to look back at some of their existing plans and programs, say to themselves, "What do we need to add here? Who's left out?"

JOHNSON:
The CDC hosts a detailed webpage on the issue of healthy aging featuring the latest roadmap and other helpful resources for public health professionals. The Alzheimer's Association also has information on the topic on its website.

Find the links in the show notes for this episode.

Thanks for listening to Public Health Review.

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And if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

This show is the production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.