The SMARRT Study’s Revelations Are Just Smart Aging
By DR. ERIC B. LARSON
In 1978, as I completed my residency and fellowship training and joined the University of Washington faculty, I had a dizzying array of interests.
Aging, and especially the aging brain and dementia, piqued my curiosity, although dementia research and care were not then in the mainstream. Demographic forces portended we would need a lot more research to understand aging processes. The predicted growth of many persons living to advanced old age is now a fact of life. But in the late 1970s, dementia occupied the backwaters of academic medicine. Back then, those who lived into their late 70s, 80s, and beyond and became impaired were typically seen as just experiencing old age or normal senility. Alzheimer’s disease was considered a cause of pre-senile dementia—described decades earlier in the rare, strange case of a middle-aged woman.
Changing demographics predicted a “silent epidemic of dementia in the elderly.” A growing fear of dementia likely contributed to the explosion of interest in Alzheimer’s disease and related dementias since the late 1970s—fueled partly by increased federal funding for research and awareness when a revered former president, Ronald Reagan, withdrew from public life with Alzheimer’s disease.
One recollection I have is of a poll asking doctors what disease they feared most. Many expected doctors might fear a common killer disease like cancer or possibly a heart attack. The surprising result was that the disease doctors feared most was Alzheimer’s disease, now recognized as the most common cause of dementia. Today, ongoing research has vastly expanded what we know about the aging brain and Alzheimer’s disease and related disorders.
No Magic Bullet Cure
Many wish for a cure. Perhaps a vaccine that might eliminate the risk altogether, or a magic bullet that provides a cure for those who develop Alzheimer’s. Nothing like this exists today.
Vast amounts of federal and industry resources have supported science in search of that “magic bullet”—a pill to prevent or cure Alzheimer’s. One drug has recently been approved and another is expected to be approved soon. These drugs are designed to remove amyloid, a degenerative protein implicated in Alzheimer’s. They are expensive, have serious side effects, and do not actually cure or prevent the disease; rather they modestly slow the rate of decline in carefully selected persons. Some smart alecks say the best way to avoid dementia as we get older is to die young!
Focus on Prevention and Risk Reduction
A smart—not a smart aleck’s—approach to epidemics like dementia is to find ways to prevent and reduce the risk of dementia as we age. Prevention research has focused on finding factors that increase the risk for dementia, especially so-called factors that are potentially reversible or at least modifiable.
The Lancet Commission on Dementia—comprised of international experts—has produced two reports and is about to publish its third. The second report estimates that 35 to 40 percent of the risk for late-onset dementia is accounted for by potentially modifiable risk factors. The keywords here are “potentially modifiable.”
A Glimmer of Hope—The FINGER Study and Trial
Is there a better, smarter way to control this epidemic? Might it be smarter to find ways to reduce risk by discovering ways to make changes based on these “modifiable” factors and see if they actually work? Several mostly international studies designed to reduce dementia risk have been published. One promising study, FINGER, or the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability, focused on nutritional guidance, exercise, cognitive training, social activity, and management of metabolic and vascular risk.
The dementia research field greeted the modestly beneficial results of the FINGER trial with enthusiasm. So-called mini-FINGER trials were launched in the U.S. and around the world. Earlier research had failed to show the cognitive benefits of efforts from changing potentially modifiable risk factors. FINGER provided a glimmer of convincing evidence supporting this concept.
Targeting Risk Factors for Better Results—SMARRT Study and Trial
A just published new report sheds more light on the prospect of modifying risk factors to reduce cognitive and dementia risk. The study known as SMARRT, or Systematic Multidomain Alzheimer’s Risk Reduction Trial, was released electronically on Nov. 23, 2023, and published in JAMA Internal Medicine journal in January. As the first personalized intervention, SMARRT focuses on maintaining or improving multiple areas of function. This is done by targeting risk factors based on participants’ risk factor profiles, preferences, and priorities. The research team from Seattle and San Francisco who designed the study believed that a personalized approach was better than the one-size-fits-all approach used in previous research. In a planning survey of 600 older adults in Seattle, we found that most were concerned about Alzheimer’s disease. They wanted to know their personal risk factors and were motivated to make changes to lower dementia risk.
The two-year study of 172 persons, ages 70-89, at elevated risk for dementia found that participants in SMARRT had a modest but statistically significant improvement in cognitive testing of 74 percent compared to the control group. Participants also had improvements in measurements of risk factors (145 percent) and quality of life (8 percent).
The SMARRT program involved participants meeting with a health coach and nurse followed by coaching sessions. Initial visits were in person but due to the pandemic, all sessions were switched to phone. In the sessions, risk factors selected by participants were reviewed. Coaches and participants met once per month. Coaches offered advice and discussed progress toward goal achievement including tracking hypertension with a home blood pressure monitor, walking a certain number of steps each day, signing up for a class, and challenges to achieving goals. In addition to tracking progress participants could add new goals. The most common risk factors that were worked on were physical activity (95.1 percent), hypertension (76.1 percent), sleep (52.4 percent) depressive symptoms (45.1 percent), and social engagement (41.5 percent). The less commonly chosen risk factors (<25 percent) were risky medications, diabetes, and smoking.
Compared to other trials of this type, the beneficial change in cognition, while modest, was greater. I believe the SMARRT results occurred because participants were motivated to try to avoid cognitive decline, were prompted to make personal goal choices, and were able to monitor and share their progress, including, for example, by tracking increased physical activity and monitoring blood pressure.
The SMARRT study results point to the “smart” approach for individuals and those working to reduce the impacts of dementia and cognitive decline in our communities.
As awareness of Alzheimer’s disease and dementia has grown, more people have become motivated to find ways to promote cognitive health. The good news is that improvements in these risk factors also promote general health and well-being. Changes don’t have harmful side effects or the high costs associated with new drugs.
The distinguishing feature—what made the SMARRT study so “smart”—was that participants chose personal targets that resonated with their lives and values. They kept track of their progress, even moving on to other targets. Smart, SMARRT moves!
Eric B. Larson, MD, MPH is a Professor of Medicine at the University of Washington. He was co-Principal Investigator of the SMARRT trial and formerly Vice President for Research and Healthcare Innovation at Group Health and Kaiser-Permanente Washington. With colleagues, he co-founded the long-running Adult Changes in Thought (ACT) study in 1986. He continues research through the UW Alzheimer’s Disease Research Center and other projects. He has participated in The Lancet Commission on Dementia since its inception. With co-author Joan DeClaire he wrote the well-received book, Enlightened Aging: Building Resilience for a Long Active Life.
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