Personalized, Multidomain Risk Reduction Strategies Show Modest Impacts on Cognition, Dementia Risk Factors

Kristine Yaffe, MD

Findings from the SMARRT study (NCT03683394) showed that over a 2-year period, patients assigned to a personalized risk-reduction intervention with health coaching and nurse visits had modest improvements in cognition, dementia risk factors, and quality of life than controls. Overall, investigators concluded that modifiable risk-reduction strategies should be considered for older adults at risk for dementia.¹

Published in JAMA Neurology, the trial featured 172 adults at an elevated risk for dementia who were randomly assigned 1:1 to either intervention or control. The intervention used a personalized, patient-centered approach delivered through a health coach and nurse with contacts in person or by telephone. Health coaching sessions were offered every 4 to 6 weeks to set goals related to risk factors chosen by participants, with more frequent visits in the first 3 months, then every 6 weeks for the final 15 months of the intervention.

After 2 years, compared with health education controls, those assigned to the intervention demonstrated larger improvements on the primary outcome, a composite modified Neuropsychological Test Battery (average treatment effects [ATE] of SD, 0.11; 95% CI, 0.01-0.20; P = .03). In addition, those on the intervention saw positive changes in PROMIS Quality of Life score (ATE, 0.81 points; 95% CI, –0.21 to 1.84; P = .12). Overall, the increase in risk factor score translated to a roughly 145% improvement in risk factor profile for those in the intervention group compared with controls.

Led by Kristine Yaffe, MD, director of the Memory Evaluation Clinic at the San Francisco Veterans Affairs Health Care System, the study assessed outcomes at baseline and 6, 12, 18, and 24 months. For those on the risk-reduction intervention, once a goal was reached, a new goal was set either for that risk factor or another risk factor as the participants preferred. Participants were also given information on selected risk factors, self-monitoring tools, and resources, depending on preference, by health coaches who had master’s degrees in social work or psychology.

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Changes in individual risk factor outcomes by treatment group were also examined, and nearly all were consistent with greater improvement in the intervention group compared with control, with trend level or statistically significant improvements in sleep, depressive symptoms, diabetes control, and social satisfaction. Even after adjusting for sex, race and ethnicity, education status, comorbidity score, and telephone assessment, the adjusted findings were almost identical to the unadjusted analyses.

Most of the cohort (92.6% of completers) answered the study satisfaction survey, with results indicating a slightly higher satisfaction with the intervention (intervention: 3.7 [SD, 0.5]; control: 3.5 [SD, 0.7]). Between the intervention and control groups, investigators recorded 24 and 23 serious adverse events (AEs), respectively; however, none were related to treatment. The intervention group reported 14 AEs possibly related to treatment whereas none were reported in the control group. The related AEs included 9 musculoskeletal complaints, 2 incidents related to anxiety, 2 elevated blood pressure readings at in-person study visits, and 1 skin rash from an activity tracker.

According to the study authors, this was the first study to test a personalized multidomain intervention for Alzheimer disease and related dementias prevention in which participants choose to work on individual risk factors and identified goals and ways to achieve behavioral change. The most common risk factors worked on were physical activity (95.1%), hypertension (67.1%), sleep (52.4%), depressive symptoms (45.1%), and social engagement (41.5%).

REFERENCE
1. Yaffe K, Vittinghoff E, Dublin S, et al. Effect of personalized risk-reduction strategies on cognition and dementia risk profile among older adults: the SMARRT randomized clinical trial. JAMA Intern Med. 2024;184(1):54-62. doi:10.1001/jamainternmed.2023.6279