Experience Corps: A Social Health Promotion Program to Improve Cognitive and Functional Health

1. Experience Corps: A Social Health Promotion Program to Improve Cognitive and Functional Health Michelle C. Carlson, Ph.D. The Johns Hopkins Bloomberg School of Public Health, Center on Aging and Health Joint Symposium: Promoting Health in Aging September 27, 2011

2. Major Societal Health Challenges to be Addressed • Compression of morbidity for an aging society • Educating the next generation: strong predictor of future health status • Health disparities: young and old • Competition for health resources between generations

3. Social Engagement as a Vehicle to Increasing Cognitive& Physical Activity • “Engagement” hypothesis: Cognitively enriching and complex lifestyle and occupational activity will boost one’s ‘cognitive reserve” (e.g., Schooler et al., 1999; Schooler & Mulatu, 2001; Verghese et al., 2003) • Physical activity exerts broad cognitive and neural benefits (Kramer et al., 2003; Colcombe, Kramer, Erickson, et al., 2004) • Social integration and engagement associated with improved cognition (e.g.,Bassuk et al., 1999; Rowe, 2004; Rowe & Kahn, 1998) • HOWEVER, retirement and age often bring a constriction of social circles: • Loss of regular access to work friends -- Friends/peers becoming disabled

4. Challenges of Physical Exercise Interventions Long-term adherence to PA interventions is abysmal(Mayoux-Benhamou et al., 2005) -- 22-76% of those who start exercise programs drop out within 6 months Spontaneous physical activity decreases with age across the animal kingdom- from worms to humans (Wilkin, et al., 2006) Particularly challenging among sedentary & other high-risk segments of the population (e.g., low SES, high BMI, restricted access to healthcare) Community-based, multi-level approaches needed

5. Generativity as Key to Successful Aging[Erik Erikson] • Leaving a legacy • Leaving the world better for future generations • Productive, meaningful engagement

6. Social Health Promotion Model of Generative Service:Growing & Maintaining Health on both Ends of Life Course • What older adults do affects their health • remaining relevant, engaged, & active • access to health promotion varies, particularly among those at risk for health disparities, where drop-out is high • Teaching children during critical developmental window: • Pressing need to close the achievement gap between disadvantaged students and their peers • An aging society’s wisdom can bring benefits to a developing generation: • Potential societal “win-win” on both ends of the life course

7. Conceptual Framework for the Baltimore Experience Corps® Trial Intervention Primary Pathways Mechanisms Outcomes Functional parameters: + strength & balance - falls Physical function (mobility) Physical Activity Global function (IADL’s) Psychosocial parameters: + social support + self-efficacy Experience Corps Participation (generative performance) Social Engagement Cognitive function Quality of Life Cognitive parameters: + cognitive reserve Changes in brain structure and function Cognitive Stimulation Health care costs (hospital & outpatient costs)

8. Experience Corps Model • Volunteers 60 and older • Serve in public elementary schools: K-3 • Meaningful roles; important needs • High intensity: >15 hours per wk • Reimbursement for expenses: $150/mo • Sustained dose: full school year • Critical mass, teams • Health behaviors: physical, social, and cognitive activity • Leadership and learning opportunities • Infrastructure to support program • Program evaluation

9. Experience Corps nationally • Designed in early 90’s (Freedman and Fried) • 1995-8: National demonstrations, 5 cities; sponsored by CNS • Ongoing implementation and expansion in 19 cities • Experience Corps Baltimore: site of program co-design, expansion, evaluation (supported by Americorps, Civic Ventures, Weinberg Foundation, CARE, City of Baltimore; Research support: NIA, Retirement Research, Erickson)

10. EC Pilot Randomized Trial: 1999-2000 • 151 volunteers >60 years • Controls wait-listed to enroll the following year • Randomized to treatment (n=72) or control schools (n = 79) • 98% retention rate in Year 1 • 4-8 months follow-up

11. Impact on K-3rd Grade Children Pilot results show positive benefit for children. In first year of program operation: • Office referrals for behavioral issues dropped by 50% in two EC schools and 34% in the other EC school. • Vocabulary scores on the PPVT-III improved in K and 1st grade students. • The percentage of children scoring “satisfactory” on the MSPAP reading test improved.

12. EC Non-EC Kindergarten Grade 1 Grade 2 Grade 3 Total

13. Impact on Volunteers: Baseline Characteristics of Experience Corps Pilot Trial Participants Age ( Range: 60-91) 60-65 31% 66-70 33% > 71 36% Gender Male 18% Race Black 92% White 8% Married 24% Education High school or less 82% Health Excellent/very good 29% Good 60% Fair 12%

14. Pilot Trial Results: Increased walking & decreased sedentary activity Fried et al.,2004

15. Pilot RCT Results: EC Baltimore; 4-8 months follow-up Tan 2006 Fried 2004

16. Targeting executive function through real-worldsocial health promotion programs

17. Targeting Executive Function:Why Important? • Ability to plan, initiate, and carry out a course of action • Involves: • Ability to shift flexibly, modify goals • Inhibit & update irrelevant or distracting information • Age-related changes in executive function may precede changes in memory (Carlson et al., 2009) • Integral to performing many independent activities of daily living (e.g., Grigsby et al., 1998; Carlson et al., 1999)

18. Program Components to Enhance Executive Function • Embraces environmental complexity: • Broad vs. specific intervention design • Embedded within everyday activity • Multiple roles (e.g., tutoring, library): • Flexibly shifting among roles • Variety; stimulating multiple domains of ability • Problem solving with team members & teachers • Potential for broad generalizability to multiple cognitive and functional outcomes

19. Improvements in those With Poor Executive Function at Baseline Carlson, Saczynski, Rebok, et al., 2008

20. Conclusions: Population-based Approaches to Healthy Aging • Generative potential attracts and fulfilled generativity retains older adults • Lifestyle activity-- 15-hour/week dose of increased physical, cognitive and social activity, each of which is neurocognitively protective • High long-term retention: sustained dose of prevention • Target Multiple Systems to Compress morbidity: • Disability, mobility, executive function, memory • Reduce Health disparities • Designed for a win-win • Harnessing social capital of aging society

21. Do Improvements Get Under Skin?EC Functional Brain MRI (fMRI) Pilot Study of EF Demographics of an At-Risk Group Carlson, Erickson, Kramer, Colcombe, Bolea, Mielke, Rebok & Fried, 2009

22. EC participants show improved performance on difficult condition after 6 months exposure Congruent <<<<< Incongruent <<><<

23. Intervention-specific change in executive attention Carlson, Erickson, Kramer, Colcombe, Bolea, Mielke, Rebok & Fried, 2009

24. Preliminary Conclusions • Change in patterns of activation are evident • Behavioral RT and fMRI data correspond in showing improved ability to selectively attend during the most demanding condition • Increased activity in attentional control regions suggests more successful filtering/inhibiting of conflicting information • Corresponding reduction in dACC suggests better filtering of conflicting information • Consistent with patterns observed in a 6-month physical activity intervention (Colcombe et al., PNAS 2003)

25. Large-scale RCT of EC: Baltimore • Evaluation funded by NIA BSR and initiated in Fall 2006 & concluding Dec. 2011 • Randomized: • 702 60 yrs. and older to EC or low-activity control • 30+ public elementary schools to EC or control • Exposure: 2 years of high-intensity service • Outcomes: • Physical: Disability, mobility, walking speed • Cognitive: Memory, executive fx • IADLs: Hopkins Med. Schedule

26. Demographic & Health Characteristics of BECT Participants Demographic characteristics:

27. Brain Health Substudy (BHS) Examine the direct effects of enriched environment on brain systems and function Incorporate physiologic & biologic measures to help: characterize the baseline health of this cohort inform the larger behavioral trial by identifying mechanisms by which activity gets under the skin BHS N=120 Experience Corps RCT N=702

28. BHS Neurophysiologic Measures as Intermediate to Behavioral Outcomes Functional and Structural Brain Health Fasting Blood to obtain Lipid, Inflammatory biomarkers of baseline health and intervention efficacy CNS Integrity: Salivary Cortisol Objective Measure of Physical Walking Activity: Step Activity Monitor Step Activity Monitor (SAM) Functional MRI Salivary Cortisol

29. Accounting for Baseline Heterogeneity in Brain Structure Healthy Brain Brain Atrophy

30. Characterizing physical activity in a sedentary cohort: • Participant recorded an average of 7.0 minutes per day at moderate-intensity (≥100 steps/min), while accumulating 337.1 minutes at low-intensity (<100 steps/min), and 685.1 minutes of sedentary activity (0 steps/min). Clinical guidelines recommend at least 30 minutes per day of moderate-intensity activity, however low-intensity activity may be associated with health benefits. Varmaet al., submitted

31. Association between daily step activity and hippocampalvolume, a structure important to memory and dementia risk Low levels of physical activity matter Avg. steps/day Max steps in 10 min Varma et al., in preparation

32. Less Active More Active Change in Distance Between Locates (Less Active) Change in Distance Between Locates (More Active) Distance Away from Home Over Time (Less Active) Distance Away from Home Over Time (More Active)

33. Conclusions for Community-basedHealth Promotion • Social engagement models may serve as effective vehicle to promote & sustain cognitive and physical activity • In EC, social contract with children and peers gets them out of bed each morning & walking to & in school • Baseline step activity & hippocampal volume data suggest that such changes may be sufficient to derive benefits • Leverages abilities improving with age to boost those declining & the developmental need to give back: • Volunteers embedded & empowered within the school community to make a difference • Reaches those who are sedentary at baseline and may not otherwise exercise for personal health

34. Investigative Team Linda Fried (PI) Dean, Columbia Mailman School of Public Health George Rebok (co-PI) Erwin Tan Elizabeth Tanner Jeanine Parisi Paul Willging Teresa Seeman Tara Greunewald University of California, Los Angeles Sylvia McGill Greater Homewood Community Corporation Brain Health Substudies: Vijay Varma Dana Eldreth Greg Harris Yi-Fang Chuang Natalie Bolea Michelle Mielke Chris Seplaki University of Rochester, NY Arthur Kramer University of Illinois, Urbana Kirk Erickson University of Pittsburgh

35. Funding Acknowledgments • NIA BSR Grant # P01AG027735-03, administrative supplement • Greater Homewood Community Corporation • Johns Hopkins OAIC Pepper Center Grant #P30AG021334 • Johns Hopkins Neurobehavioral Research Unit • S.D. Bechtel Award

36. Expanding Methods to Assess Predictors of Variability in White Matter Connectivity: DTI

37. Daily Step Activity Total Steps per day: 8662 Max. 10 min of activity (54 steps/min) Total Steps per day: 2274 Max. 10 min of activity (22 steps/min)

38. Carlson Experience Corps Follow-up Grant SENSES EMADevices ACTIVITY PATHWAYS OUTCOMES HOW MUCH / WHEN AIM 1 Social -card games -church BIOLOGICAL BEHAVIORAL Hearing Structural MRI Cognitive: Executive Function Memory Processing Speed fMRI Physical Exercise -walking -other Lifestyle Activity WHERE / HOW FAR AIM 2 Psychological: Depressive Scale Generativity Functional -shopping -caring for others Vision Physical: Grip Strength 4-Meter Gait WHAT AIM 3 1. Accelerometer : Actical, Phillips Respironics Inc. 3. Smartphone: Motorola Droid Pro 2. Cellular Localization Device: P-trac Pro

39. Baseline Characteristics of an At-Risk Group: BHS Participants in EC Trial Demographic characteristics: