Cognitive decline can be slowed with personalized therapy, according to results of The Systematic Multi-Domain Alzheimer Risk Reduction Trial (SMARRT), published today in JAMA Internal Medicine. This was a randomized clinical trial that included a two-year, personalized, dementia risk-reduction intervention program. The lead author was Kristine Yaffe, MD, of the University of California, San Francisco.
Alzheimer’s disease and related dementias (ADRDs) are one of the leading causes of disability and death in the world, according to the World Health Organization. It is also estimated that up to 40% of ADRD risk might be modifiable by targeting lifestyle, medical, and behavioral risk factors.
In this study, 172 adults at elevated risk for dementia (age 70–89 years and with two of eight targeted risk factors) were recruited from primary care clinics associated with Kaiser Permanente Washington. Participants were randomly assigned to the intervention (personalized risk-reduction goals with health coaching and nurse visits) or to a health education control.
The primary outcome tracked was change in a composite modified neuropsychological test battery. Secondary outcomes were change in risk factors and quality of life (QOL).
The participants had a mean age of 75.7 years, and 108 (62.8%) were women. After two years, compared with the 90 participants in the control group, the 82 participants assigned to intervention demonstrated larger improvements in the composite cognitive score (74% improvement compared with the change in the control group), better composite risk factor score, and improved QOL.
The intervention used a personalized, patient-centered approach delivered through a health coach and nurse with contacts in person (prior to the COVID-19 pandemic) or by telephone (for those who preferred telephone prior to the pandemic and for all participants after onset of the pandemic). Health coaching sessions were offered every four to six weeks to set goals related to risk factors chosen by participants, with more frequent visits in the first three months, then every six weeks for the final 15 months of the intervention.
At the first intervention visit, the health coaches used a visual aid to facilitate conversation about the modifiable risk factors, which was individualized for each participant. A red section listed risk factors that were suboptimal for that participant, and a green section reinforced behaviors the participant was already engaged in.
Then the health coaches helped the participants set specific goals for suboptimally controlled risk factors that they were interested in working on (e.g., sign up for a class, walk a certain number of steps daily). Goals were reviewed at each coaching visit. Once a goal was reached, a new goal was set either for that risk factor or another risk factor as the participant preferred.
Time per coaching session was greater in the first three months (approximately 45 minutes), then reduced to 20 minutes for the remainder of the calls. Health coaches had master’s degrees in social work or psychology and received training in motivational interviewing techniques (e.g., eliciting values, reinforcing change). A standardized coaching manual and resources for each risk factor were provided.
Participants were given information on selected risk factors, self-monitoring tools, and resources (eg, fitness tracker, sleep workbook, brain games), depending on preference. The risk factor targets included the eight factors from inclusion criteria, but participants could also work on other non targeted health goals, such as diet and cognitive activity. Participants with uncontrolled diabetes, uncontrolled hypertension, or risky medication use received quarterly contacts from the intervention nurse.
The team used a treat-to-target approach and brief electronic communication with the primary care team as needed. For those targeting hypertension, a portable blood pressure monitor was provided. Risky medications that can impair cognition (eg, anticholinergics, sedative-hypnotics) were also identified. When a risky medication was identified, the study nurse outlined possible cognitive risks and encouraged the participant to discuss alternatives with their primary care clinician.
