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 AgingSeptember 27, 2011

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

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

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

Generativity as Key to Successful Aging

[Erik Erikson]

• Leaving a legacy• Leaving the world better for future

generations• Productive, meaningful engagement

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

Conceptual Framework for the Baltimore Experience Corps® Trial

Experience Corps Participation

(generative performance)

Physical Activity

Cognitive Stimulation

Physical function(mobility)

Social Engagement

Intervention

Global function(IADL’s)

Quality of Life

Cognitive function

Health care costs(hospital &

outpatient costs)

Primary Pathways

Mechanisms Outcomes

Functional parameters:+ strength & balance

- falls

Psychosocial parameters:

+ social support+ self-efficacy

Cognitive parameters:+ cognitive reserveChanges in brain

structure and function

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

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)

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

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.

-100

-80

-60

-40

-20

0

20

40

Change o

f Suspensio

ns

1 2 3 4 5

Change in Number of Suspensions from 2003-2004 to 2005-2006 (Original + New Schools)

Series1Series2

Kindergarten Grade 1 Grade 2 Grade 3 Total

EC

Non-EC

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%

Pilot Trial Results: Increased walking & decreased sedentary activity

Walking Distance(block) per Week

31.4%

-9.0%-15.0%

-10.0%

-5.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Intervention Control

Group

% o

f C

ha

ng

e f

rom

BL

to

FU

Fried et al., 2004

Number of TV Hours per Day

-3.9%

18.1%

-10.0%

-5.0%

0.0%

5.0%

10.0%

15.0%

20.0%

Intervention Control

Group%

of c

hang

e fr

om B

L to

FU

Pilot RCT Results: EC Baltimore; 4-8 months follow-up

EC participants n=59

Controls N=54 P value(adjusted)

More physically activeAt follow-up 53% 23% .01

Kcal/wk- difference, baseline to f/u:Overall:

Low activity, baseline

810 1130 (+ 40%)

420 880 (+110%)

670 560 (-20%)

490 500 (+ 2%)

.52

.03

Stronger at follow-up 44% 18% .02

Tan 2006

Fried 2004

Targeting executive function through real-world social health

promotion programs

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)

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

-12%

-26%

37%

9%

40%

44%44%

51%

-30%

-20%

-10%

0%

10%

20%

30%

40%

50%

60%

Per

cen

t Im

pro

vem

ent

(bas

elin

e to

fo

llow

up

)

Control

Intervention

TMT A TMT BRey-O DelayedECA Word List Memory Delayed

Carlson, Saczynski, Rebok, et al., 2008

Improvements in those With Poor Executive Function at Baseline

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

Characteristic Participants Controls

Age, mean years 68 (r: 62-78) 68 (r: 63-75)

Female, n (%) 8 (100) 9 (100)

African American, n (%) 8 (100) 9 (100)

Education, mean years 12 12

Widowed, n (%) 5 1

MMSE, mean 24.5 25.6

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

EC participants show improved performance on difficult condition after 6 months exposure

Reduction in Flanker I nterference by Group and Cue Size

-20

0

20

40

60

80

100

120

140

EC Control

Group

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ed

ucti

on

in

In

terf

ere

nce E

ffect(

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ds

Congruent

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Intervention-specific change in executive attention

Carlson, Erickson, Kramer, Colcombe, Bolea, Mielke, Rebok & Fried, 2009

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 conditiono Increased activity in attentional control regions suggests more

successful filtering/inhibiting of conflicting informationo 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)

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

Demographic & Health Characteristics of BECT Participants

Demographic characteristics:N=702Age 67

Education 41 % ≤ 12th Grade25% ≥ 16 Grades

Sex (% Female) 85%

Racial (% African American) 89.4%

Income 24% < $10,00050% < $25,000

Mini-Mental State Exam (MMSE) 28

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 skinExperience Corps

RCT

N=702

BHSN=120

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)Salivary CortisolFunctional MRI

Accounting for Baseline Heterogeneity in Brain Structure

Healthy Brain

Brain Atrophy

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.

Varma et al., submitted

7.0

337.1

685.1

Moderate-in-tensity activityLow-intensity ac-tivitySedentary activity

2.5

33

.54

4.5

0 5000 10000 15000 20000 25000avg_steps

Fitted values Lhippocampus

2.5

33.

54

4.5

20 40 60 80 100 120avg_max10

Fitted values Lhippocampus

Association between daily step activity and hippocampal volume, a structure important to memory and

dementia risk

Avg. steps/day Max steps in 10 min

Varma et al., in preparation

Low levels of physical activity matter

02

46

8

Dis

tan

ce (m

iles)

0 6 12 18 24 30 36Time - 36hrs

Change in Distance Between Locates (VJ)

05

10

15

20

Dis

tan

ce fr

om

Hom

e (

mile

s)

0 6 12 18 24 30 36Time - 36hrs

Distance Away from Home Over Time (VJ)

05

10

15

Dis

tan

ce fr

om

Hom

e (

mile

s)

0 6 12 18 24 30 36Time - 36hrs

Distance Away from Home Over Time (GH)

05

10

15

Dis

tan

ce (m

iles)

0 6 12 18 24 30 36Time - 36hrs

Change in Distance Between Locates (GH)Change in Distance Between Locates (Less Active)

Distance Away from Home Over Time (Less Active) Distance Away from Home Over Time (More Active)

Change in Distance Between Locates (More Active)

More ActiveLess Active

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

Investigative TeamLinda Fried (PI)Dean, Columbia Mailman School of

Public Health

George Rebok (co-PI)

Erwin Tan

Elizabeth Tanner

Jeanine Parisi

Paul Willging

Teresa Seeman

Tara GreunewaldUniversity of California, Los Angeles

Sylvia McGillGreater 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•

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

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

Total Steps per day: 8662

Max. 10 min of activity(54 steps/min)

Max. 10 min of activity(22 steps/min)

Daily Step Activity

Total Steps per day: 2274

HOW MUCH / WHEN

AIM 1

WHAT

AIM 3

WHERE /HOW FAR

AIM 2

Social -card games -church

Physical Exercise -walking -other

Functional -shopping -caring for others

Structural MRI

fMRI

Cognitive: Executive Function Memory Processing Speed

Psychological: Depressive Scale GenerativityPhysical: Grip Strength 4-Meter Gait

OUTCOMES

BIOLOGICAL BEHAVIORAL

ACTIVITY PATHWAYSEMADevices

Carlson Experience Corps Follow-up Grant

Lifestyle Activity

3. Smartphone: Motorola Droid Pro

2. Cellular Localization Device: P-trac Pro

1. Accelerometer : Actical, Phillips Respironics Inc.

Vision

Hearing

SENSES

Baseline Characteristics of an At-Risk Group: BHS Participants in EC Trial

Demographic characteristics:N=120Age (mean) 67

Education 41 % ≤ 12th Grade25% ≥ 16 Grades

Sex 72% = Female

Racial/Ethnic group 89.4% = AA

Income 24% < $10,00050% < $25,000

MMSE (mean)WRAT (mean)

27 56