Alzheimer Disease and Related Cognitive Impairment in Older Adults: A Narrative Review of Screening, Prevention, and Management for Manual Therapy Providers

Abstract

Objective

The aim of this narrative review was to review literature relevant to manual therapists about cognitive impairment, together with screening, potential treatment, and prevention modalities.

Methods

A literature search of AMED (Allied and Complementary Medicine Database), CINAHL (Cumulative Index of Nursing and Allied Health Literature), PubMed, and MEDLINE was conducted with the search terms “cognitive decline,” “cognitive impairment,” “screening,” and “prevention.” We reviewed current screening practices, including functional exams, imaging, and laboratory testing. We reviewed current potential preventive measures and treatments being implemented in practice.

Results

We selected 49 resources for this narrative summary. The Montreal Cognitive Assessment and Mini-Mental State Exam are recommended screening tools. Imaging and laboratory testing are not recommended in screening for cognitive decline. Promotion of healthy, active living through physical and mental activities may assist with prevention of cognitive decline.

Conclusion

Cognitive decline affects a large proportion of the US population. Recognizing signs and symptoms of this condition starts with individuals, caretakers, family members, and health care providers. Health care providers should utilize the most appropriate screening tools to assess the presence of cognitive conditions.

Introduction

Cognitive impairment (CI) is defined as “when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life.”¹ Cognitive impairment can occur in the domains of memory, learning ability, language, ability to perform activities of daily living (ADLs), attention, and motor skills.² Changes range from mild to severe, with the worst cases often leading to Alzheimer disease (AD) or related disorders, such as dementia.³ Symptoms are often minor in the beginning and go unnoticed by relatives or friends, rendering screening for this condition more imperative for clinicians.

Approximately 5 million adults older than 65 years in the United States are affected with AD and declining cognition.³ These individuals and their families are all affected in some meaningful way. Cognitive decline, for the purposes of this review, is the process of increasing symptoms of CI, such as memory loss. Cognitive impairment can place patients at risk for falls, fractures, and early death.^{4, 5, 6}

Providers should screen for CI and pertinent past medical history, including osteoporosis, rheumatoid arthritis, and connective tissue disorders. Caution should be used when applying manual therapy techniques to people with these conditions.⁷

Given that chronic pain can contribute to CI, individuals at risk for CI present to manual therapy providers for pain complaints.⁸ Recently, with the onset of the COVID-19 pandemic, some attention has been placed on the effects that infections have had on an individual's cognition, especially in those over 65 years of age. Public health screening initiatives may act to mitigate progressive symptoms and potentially reduce risks of long-term or detrimental consequences for those afflicted with CI.² The objective of this narrative review was to examine current literature and evidence-based approaches to identify risk factors for CI, together with addressing screening, treatment options, and prevention modalities in individuals who may present to manual therapy providers. Secondarily, this review provides patient education and advocacy resources.

Methods

A literature search of medical databases, including CINAHL (Cumulative Index of Nursing and Allied Health Literature), PubMed, MEDLINE, and AMED (Allied and Complementary Medicine Database), was conducted in May 2021, including studies from January 1, 2000, until May 15, 2021, with the search terms “chiropractic,” “cognitive decline,” “cognitive impairment,” “screening,” and “prevention.” Limited studies were produced, including “chiropractic” in search terms; therefore, other searches were conducted excluding the term “chiropractic.” A total of 1963 articles dating back to 1988 were found in a PubMed search of “cognitive decline impairment screening and prevention.” The primary investigator limited the search to exclude articles not in the English language and prior to 2000 to include studies and literature encompassing this topic over the past 20 years. This resulted in 1929 articles. Filters were then set to include meta-analysis, randomized controlled trials, and systematic reviews. This produced 207 results. “AND treatment” was additionally added to the search terms, and this resulted in 169 articles. Due to the volume of literature found in the PubMed search, CINAHL, AMED, and MEDLINE were excluded. Additionally, a simple Google search for patient advocacy resources was conducted. This search was “Cognitive decline and/or impairment patient resources.”

Results

We used 49 resources for this narrative summary, with additional references for the expansion of the topics covered, such as referral options addressed in the following. Additional resources were included in this review and are attached in a supplemental file for reference and advocacy groups (see Supplementary material).

Discussion

Cognitive impairment is a public health concern impacting many adults. Multiple chronic diseases have demonstrated increased risk factors for CI. Many of these conditions are seen in patient populations that report to manual therapy providers for care and management. Recognizing risk factors is important, and recommending appropriate lifestyle changes may help prevent or delay onset. The following is a summary of our findings.

Recognizing Risk Factors

Cognitive impairment is associated with the older adult population, with a prevalence of 11.7% to 14.9% in US adults over 65 years of age.^9,10 Multiple chronic diseases and conditions have been shown to increase the risk factors for cognitive decline, including heart disease, kidney disease, chronic obstructive pulmonary disease, diabetes, obesity or metabolic syndrome, chronic and persistent pain, and infections, such as HIV and COVID-19.^{2,8,11, 12, 13, 14, 15} Many of these conditions are common among the older adult population in the United States. Other risks for cognitive decline or CI include genetic predispositions, depression, polypharmacy, and physical frailty.^2,16 Current signs of confusion, forgetfulness, or disassociation from conversation should acutely alert practitioners to potential cognitive decline or CI. It is important for clinicians to screen for CI or decline in patients, as delay can lead to missed or stalled diagnoses of conditions such as Parkinson disease and AD.

Screening for CI and Decline

Screening for CI is important for patients with risk factors. Clinicians in a variety of specialties are often the first to address patient and family concerns about memory loss, change in mental status, and the possible development of dementia or AD. If clinicians fail to evaluate memory or cognitive complaints, treatment of comorbid conditions and underlying disease processes may be deterred.¹⁷ Cognitive conditions or CI may worsen over time and result in concerns of safety for the patient, clinician, or others.¹⁸ Although most manual therapy providers lack the privilege to order some of the tests we will review, we thought it prudent to include this information, as it is important for general knowledge when potentially managing these cases with other providers. Screening is addressed in the following.

Screening Instruments

The Mini-Mental State Exam (MMSE) and the Montreal Cognitive Assessment (MoCA) screening tools have been heavily researched and accepted in identifying CI. Both instruments meet all psychometric and clinical utility criteria for properly identifying CI.¹⁹ A recent meta-analysis of 23 studies demonstrated the MoCA to be superior to the MMSE in discrimination between mild cognitive impairment (MCI) and no impairment in individuals over 60.²⁰ MCI is the stage between expected cognitive decline of normal aging and a more serious cognitive decline that is dementia or AD. A similar review of 34 articles confirmed these findings, with MoCA being superior in the detection of MCI. Both tools can accurately screen for AD, though MoCA is more difficult than the MMSE, as MoCA includes executive function, higher level language, and a more complex visuospatial processing exam.²¹ Both assessments are available for clinicians and can be performed in an office or virtually (via video-on-demand/video telehealth services.) Though, virtual screens will require appropriate adaptations and instructions to adapt to digital services. These screening instruments utilize a combination of testing in global cognition and domains, including memory, orientation, attention, and language. The MMSE has categorized levels of CI into 3 classifications based on the following scores: “no cognitive impairment,” “mild cognitive impairment,” and “severe cognitive impairment.” The MoCA classifies scores into the following 4 categories: “normal,” “mild cognitive impairment,” “moderate cognitive impairment,” and “severe cognitive impairment.”²² Both the MoCA and MMSE take approximately 10 minutes for patients to complete. There are courses and training available for clinicians to ascertain more information regarding analysis and understanding of the MoCA at the official MoCA Test Inc website (see screening resources in the Supplementary material). The MMSE can be found free at oxfordmedicaleducation.com, and the MoCA can be found free at mocatest.org.

Other screening tools exist for secondary and tertiary care assessing CI. Many of these tests are utilized by clinicians for MCI screening. A list of screening instruments and their components are provided in Table 1.^23,24 The AD8 Dementia Screening Interview is an emerging screening tool that can be beneficial in virtual use, given COVID-19 limitations. The AD8 screening tool has shown great sensitivity in detecting early CI.²⁵ It is beneficial, as the screen does not have to be conducted face-to-face and takes approximately 3 minutes to administer. The DemTect is a screening tool used predominantly in Germany. Despite having a high sensitivity and specificity for detecting CI, there are limited studies available to support the universal use of this screening tool at this time.^26,27

Table 1.

Components, Sensitivity, and Specificity for a Short List of Commonly Used Screening Tools for Cognitive Impairment^20,21

Instrument	Sensitivity	Specificity	Components of the Test
Brief (<10 min)
MMSE	0.88	0.86	Orientation, memory, language, attention, and visuospatial
MoCA	0.9-1.0	0.87	Orientation, memory, language, attention, and executive function
CDT	0.67-0.98	0.69-0.94	Visuospatial and executive function
AD8	1.00-0.82	0.96-0.94	Memory, orientation, judgment, and function
Mini-Cog	0.76-0.99	0.85-0.96	Memory, visuospatial, and executive function
MIS	0.43-0.86	0.93-0.97	Memory
DemTect	1.00	0.92	Memory, language, and executive function
Neuropsychological batteries (>20 min)
ACE-R	0.84-0.94	0.89-1.00	Orientation, memory, language, attention, visuospatial, and executive function
CAMCOG	0.92	0.96	Orientation, language, memory, attention, praxis, calculation, abstract thinking, and perception

ACE-R, Addenbrooke cognitive examination revise; AD8, Ascertain Dementia 8; CAMCOG, Cambridge cognitive examination; CDT, clock-drawing test; MIS, memory impairment screen; MMSE, Mini-Mental State Examination; Mini-Cog, mini-cognitive; MoCA, Montreal cognitive assessment.

Neuroimaging Screens for Cognitive Impairment and Decline

Neuroimaging, such as magnetic resonance imaging and computed tomography, can play a role in ruling out structural brain lesions in individuals.^{28, 29, 30} This type of imaging can aid in ruling out fractures (following traumatic head injury), cerebral hemorrhages, or other masses that may be associated with conditions, such as cerebral vascular accidents, concussions, and tumors.^{31, 32, 33} However, these forms of neuroimaging are not currently accepted as a means of diagnosing CI or decline in individuals. The diagnosis of CI remains clinical with a multifaceted approach. However, one modality growing in popularity is positron emission tomography (PET.) In recent studies, PET has shown great accuracy (89%) in the diagnosis of AD, with a 94% sensitivity and 73% specificity.³⁴ Several tau PET tracers have been successfully developed and used for clinical trials in the diagnosis of AD. Although more studies will be necessary, this is a sign that PET may have a future role in neuroimaging for CI. The increasing technology of neuroimaging may add greatly to future clinical trials.

The American Academy of Neurology (AAN) currently does not recommend imaging in the diagnosis of CI. Neuroimaging is more useful in ruling out fractures, masses, lesions, or cerebral hemorrhaging when warranted. The AAN does, however, recommend routine neuroimaging for individuals who have diagnoses of dementia to evaluate progression or stages of the condition.³⁴

Screening for Biological Markers

There are a variety of biological markers that aid in the diagnosis of cognitive conditions. Biological markers are also used in cases to rule out potentially reversible forms of dementia or CI. These various laboratory tests are completed through blood and cerebral spinal fluid (CSF) samples or a combination of both. Blood sampling, as with imaging, is not specific for AD or dementia but rather aids in recognizing conditions impairing cognition. This text will separate some of these screenings into additional “sub” subsections.

Blood and Urine Screening for Endocrine and Metabolic Disorders

The AAN recommends screening for certain metabolic and endocrine disorders in individuals suspected of having CI.³⁵ A variety of potentially reversible forms of CI include drug and alcohol abuse, folate deficiency, thyroid dysfunction, anemia, and severe infections.^36,37 Additionally, dehydration and conditions, such as urinary tract infections, may result in delirium and reversible CI.³⁶ Manual therapy providers can order simple laboratory testing through blood draws and urine samples to help role out these forms of disease (Table 2). Due to the low-cost nature of these tests, it may be valuable for manual therapy providers to order these screens to quickly identify any imbalances that may be contributing to CI.

Table 2.

Potentially Reversible Dementia Other Than Alzheimer Disease^36,37

Screening Test	Sample	Dementia Association
Vitamin B12 (cobalamin)	Blood	B12 deficiency
T4 (free thyroxine)	Blood	Thyroid disorder
TSH	Blood	Thyroid disorder
CBC	Blood	Anemia, infection
Electrolytes	Blood	Na+, K+, Cl−, CO2, pH imbalances
CRP	Blood	Inflammation
ESR	Blood	Inflammation
HIV antibody	Blood	HIV infection/AIDS
Drug screen	Urine	Illicit drug use

AIDS, acquired immunodeficiency syndrome; CBC, complete blood count; CI⁻, chlorine; CO₂, carbon dioxide; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; HIV, human immunodeficiency virus; K⁺, potassium; NA⁺, sodium; pH, potential hydrogen; TSH, thyroid-stimulating hormone.

CSF Samples: Senile Plaques and Neurofibrillary Tangles

Research has demonstrated amyloid-β acting as the predominant component of senile plaques.³⁸ Senile plaques are polymorphous beta-amyloid protein deposits found in the brain in AD cases. Amyloid-β is commonly accepted as the predominant driving factor in AD development.³⁹ Tau proteins were discovered to be the major contributing component of neurofibrillary tangles, also contributing to cognitive decline and impairment with AD. Increase in plasma p-tau217 was 5 times higher in patients with AD compared with healthy controls. These proteins can be located via PET scans or CSF samples. Due to the high-cost nature of PET scans, this screening is not recommended for individuals thought to have or be at risk for CI at this time (see previous). As well, CSF testing is not recommended due to high costs and procedure risks. However, future investigations of blood testing for these proteins may change these recommendations.

The Role of Lewy Bodies

Lewy bodies (LB) are alpha-synuclein protein brain congregates that are classically associated with dementia and Parkinson disease. LB dementia differs from Parkinson as the CI appears first, whereas Parkinsonian dementia is predicated by motor symptoms. Alzheimer disease will not demonstrate LB as that condition is characterized by amyloid plaques, as mentioned previously. The accumulation of LBs is associated with reduced acetylcholine production, which is important in memory and learning. It is estimated that 1 million individuals in the United States are affected by LB dementia. Though these proteins provide clues into the presence of CI conditions, LBs can only be verified on autopsy and are not currently useful or recommended in a routine screening or clinical diagnosis.^40,41

Treatment, Referral, and Comanagement Strategies for Manual Therapy Providers

At present, no cure exists for AD and related disorders, and early screening, diagnosis, and prevention strategies may be beneficial for these individuals. Patient needs require a team of professionals and caregivers to help monitor cognitive symptoms. Symptomatic treatment remains the only current option. Cognitive and behavioral or mood symptoms like depression, anxiety, anger, and irritability may progressively worsen as time proceeds without interventions.

Chiropractors and Physical Medicine and Rehabilitation (PM&R) specialists may play a role in pain management for these patients. Physical and occupational therapy can aid in the retraining of patients to safely perform ADLs. Specialists, such as neurologists, cardiologists, and primary care providers, play a role monitoring patient progress, medication, treatment, and education. Caregivers also play a role aiding the individual with specific needs. Education for caregivers in identifying worsening of symptoms, lifestyle changes, and continued aid for individual ADLs is vitally important. Contact with the patient's family or caretaker is of great importance to ensure prognosis. The following are example situations in which referrals may be made by manual therapy providers.

Neurology

If the patient is at risk for CI and screening tools, such as the MoCA or MMSE, have been administered and demonstrate mild or severe CI, a referral to a neurologist would be beneficial for the patient's condition. A specially trained neurologist can evaluate the extent of the CI and intervene with certain treatments. They may wish to apply detailed evaluation, such as Stroop Task, Cambridge Cognitive Examination, and Mattis Dementia Rating Scale, which may help distinguish involvement of the basal ganglia. This includes chiropractors with advanced training in neurology as to have been awarded Diplomate status. Further, if the patient is suspected of having undiagnosed Parkinson disease (signs of MCI, “cogwheel” rigidity, etc), a neurological referral would be of benefit.

Primary Medical Care Provider

Primary care referrals are extremely important in the cases of individuals suspected of having CI. These providers generally assume the role of a leader in the patient's health care. If a patient is suspected of having CI by a manual therapy provider, it would be of benefit to express these concerns to the patient's primary medical physician. This also provides an opportunity of comanagement of the suspected CI between providers. The medical physician can examine potential causes of reversible dementias, such as urinary tract infections, hydration issues, or polypharmacy, and accordingly adjust medication.

Physical Medicine

Physical medicine, for the purposes of this review, refers to chiropractors, physical therapists, occupational therapists, osteopathic physicians, and physiatrists or PM&R specialists. Chiropractic care, through manual therapy and joint manipulation, may provide chronic pain management for individuals with or without CI.^{42, 43} Given chronic pain can increase the risk of CI, these therapies may be beneficial for patients with CI.

Each physical medicine specialty offers a unique approach to care and interventions. One strategy that may help differentiate referral options is to distinguish any disruptions of the patient's ADLs. If patients suspected of having CI are in need of supervised exercise to safely perform physical activities, a referral to physical therapy might be considered.⁴⁴ However, if patients suspected of having CI are struggling with ADLs, such as bathing, tying shoes, and so on, a referral to occupational therapy may be beneficial.⁴⁵ Further pain management requiring pharmaceutical intervention or potentially osteopathic manipulation may benefit from referral to PM&R or an osteopathic physician.⁴⁶

Psychology

Behavioral and mood changes include increased signs of anger, depression, anxiety, and irritability (as mentioned previously). If patients with suspected CI are demonstrating behavioral or mood changes, a referral to a psychologist may be beneficial.⁴⁷

Cardiology

At times, individuals with CI may also experience cardiac morbidities, such as heart failure and/or coronary artery disease. Given this medical history, referral to cardiology would be helpful to ensure the conditions are well managed. Further, cardiac rehabilitation may be beneficial as treatment options for those with cardiac conditions.⁴⁸

Prevention Strategies for CI

Prevention of CI appears to be the foremost strategy in delay of dementia and AD. Evidence suggests that aerobic exercise is associated with changes in cognition and neuropsychiatric symptoms.⁴⁹ The most effective prevention tactics are classified into the following 4 groups: pharmacological interventions, over-the-counter supplementation, physical activity (PA), and cognitive training. This text will focus on PA and cognitive training, though for reference, we have included a table of commonly used medication and supplementation (Table 3). Furthermore, education on substance abuse and its psychological impacts should be addressed.

Table 3.

Common Prescription Drugs and Supplements for Cognitive Impairment^{50, 51, 52, 53}

Type	Drug or Supplement Name	Class	Indication	Side Effects
Prescription drug	Donepezil, rivastigmine, or galantamine	Anticholinesterase inhibitor	Mild to moderate AD	Diarrhea Nausea/Vomiting Weight loss Headaches Insomnia
Prescription drug	Memantine	NMDA receptor antagonist	Moderate to severe AD	Dizziness Headache Confusion Diarrhea Constipation
Prescription drug	Aducanumab	Anti-amyloid therapy	MCI in AD	Headache Falls Diarrhea
Over-the-counter	Fish oil (DHA, EPA)	Lipid-lowering agent	MCI and AD	“Fishy” taste in mouth Heartburn Loose stools Nosebleeds
Over-the-counter	Cobalamin (vitamin B12)	B vitamins	B12 deficiency and MCI	Paresthesia of hands and feet Nausea/vomiting Diarrhea Headache

AD, Alzheimer disease; DHA, docosahexaenoic acid; EPA, eicosapentaenoic acid; MCI, mild cognitive impairment; NMDA, n-methyl-D-aspartate receptor.

Physical Activity

In 2011, the American Heart Association concluded that physical activity protects against cognitive decline, based off a large-scale meta-analysis.⁵⁴ Aerobic exercise and strength training have demonstrated positive effects on different body systems and functions. Research suggests that PA and exercise can improve cognitive performance among patients with CI, offering a potential means of both prevention and treatment.⁵⁵ However, it is unclear which combinations of frequency, intensity, time, and specificity of exercise can exert the best improvement on cognition of older adults diagnosed with dementia or AD. Exercise and PA have been shown to benefit cognition by increasing cerebral blood flow.⁵⁴ In older adults, exercise is demonstrated to increase neurotrophic factors, such as brain-derived neurotrophic factor, insulin-like growth factor-1, and vascular endothelial growth factor, stimulating neurogenesis and synaptic plasticity.⁴³ Exercise has demonstrated a reduction of blood pressure, obesity, proinflammatory activity, and improved lipid profile. Adaptations that occur in response to exercise lead to better cerebral blood flow and improved oxygenation of neural regions governing cognition.⁵⁶

Low- to moderate-intensity exercises, such as cycling, had similar benefits to high-intensity exercises in increasing blood flow.⁵⁷ Neural blood flow is limited by the function of the vessels carrying the blood through the carotid, vertebral, and middle cerebral arteries.⁴⁶ In an aging population, the risk of attempting higher-intensity exercises may not outweigh the benefit of prevention of cognitive dysfunction.⁵⁴

Moderate-intensity exercise results in acute augmentation of blood flow to the brain.⁵⁴ One study demonstrated that a 2-day per week program that included aerobic exercises, strength training, and postural balance training was effective in improving logical memory and cognition and maintained brain atrophy rates compared with the control group.⁵⁸ Research has found a significant reduction in activation intensity of 11 brain regions by functional magnetic resonance imaging after a 12-week supervised treadmill walking routine, suggesting exercise intervention enhances neural efficiency.^56,59,60

A large-scale randomized controlled trial demonstrated that a “multidomain intervention (diet, exercise, cognition, and vascular risk management) and regular health advice” reduced long-term CI conditions.⁵⁷ This study was performed on individuals 60 to 77 years old, and researchers believe this system can be implemented for a “large elderly population at increased risk for dementia.”⁵⁷

To date, no standard strategy of exercise intervention for cognitive decline has been globally accepted. However, trials, such as the FINGER trial, show promise of potential interventions for prevention of CI.⁵⁷ Combining mental and physical exercises, including aerobic and strength training, may be more effective than either alone.⁵⁷ Cognitive decline is multifactorial, and a singular intervention can be insufficient.

Cognitive Training for Individuals With MCI, Dementia, or AD

Cognitive therapy includes interventions aimed at improving memory, learning, perception, language, and thinking and reasoning. Learning a new language, playing cards, and completing a puzzle are examples of cognitive training that have been demonstrated to improve cognition.⁶¹ Computerized cognitive training (CCT) involves computerized cognitive exercises targeting specific neural networks to potentially improve cognition through neuroplasticity. Research has revealed small to moderate positive treatment effects with CCT compared with control interventions in global cognition and memory and might be a positive strategy to promote healthy cognitive aging in older adults.⁶¹

Although manual therapy providers cannot directly treat CI, it is possible to comanage these conditions. Manual therapy providers may be able to play a significant role in the preventive measures that may reduce incidence of cognitive decline in the adult population. It is the opinion of the authors that public health outreach and a devoted initiative to bring awareness of CI to the general population may play a role in reducing incidences of this condition through implementation of lifestyle changes. Implementing the appropriate screening measures may help in reducing health care costs, such as expensive imaging exams or laboratory testing. As results of this review indicate, laboratory testing and neuroimaging for cognitive decline or CI are not recommended. The exception is that there is suspicion of a post-traumatic lesion, cerebral vascular accident, or tumor, in which case appropriate imaging modalities may be ordered. These tests are expensive and not particularly reliable for diagnostic purposes outside of these exceptions. Manual therapy providers can certainly administer screening tools, such as the MMSE and MoCA, for suspected CI in their patients. However, providers should become familiar with local neurologists, geriatricians, psychologists, and mental health specialists to ensure appropriate referral and comanagement options for any individual suspected of having CI. The overarching finding from this review highlights that the promotion of lifestyle changes to include mental and physical activity is the predominant intervention chiropractors can engage in when managing individuals with CI or decline.

Limitations

This review did not use a systematic approach to search or evaluate the literature. Literature was drawn from several data sources between 2000 and September 2021. It is possible that relevant articles were missed and, therefore, not included in this paper. Other studies that focused on specific populations, such as Parkinson disease case studies, or mental state disorders, such as bipolar depression, were not included in this review.

Conclusion

Cognitive impairment affects a large proportion of the US population. Recognizing signs and symptoms of this condition starts with individuals, caretakers, family members, and health care providers. Health care providers should utilize the most appropriate screening tools, such as the MoCA and MMSE, to assess the presence of cognitive conditions. Imaging is unlikely to provide any pertinent information regarding the patient's condition, but it can be helpful in other circumstances, such as trauma. Cerebral spinal fluid and blood samples are not recommended as part of the routine screening process for CI. Recognizing risk factors, signs, and symptoms is important in the early prevention of progression of this condition. Promotion of healthy active living through physical and mental activities remains the most evidence-based approach to prevention of cognitive decline. To date, no standard strategy of exercise intervention for cognitive decline has been globally accepted. Cognitive decline is multifactorial, and a singular intervention can be insufficient; thus, combining mental and physical exercises, including aerobic and strength training, may be more effective than either alone.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): C.P., C.R.

Design (planned the methods to generate the results): C.R.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): C.P.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): C.R.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): C.R.

Literature search (performed the literature search): C.R., J.A.

Writing (responsible for writing a substantive part of the manuscript): C.R., J.A.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): M.H., C.P.

Practical Applications.

• •Alzheimer disease and cognitive decline affects many older adults.
• •Caretakers, family members, and health care providers should be able to recognize signs and symptoms.
• •Health care providers should utilize the most appropriate screening tools to assess the presence of cognitive conditions.

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