Promoting Cognitive Health

Abstract

Growing evidence suggests that healthy behaviors such as being physically active, having a heart healthy diet, and being socially involved may promote cognitive health. The United States has recently begun encouraging such behaviors for that purpose. To help evaluate the diffusion of this policy, we sought to measure a baseline of activity in this area. We examined Web sites of 156 large health care systems, the health departments of all 50 states and the 20 largest US cities, and 181 nationally accredited senior centers, to identify information, products, programs, or services recommended for cognitive health. Among health care systems, 40% promoted cognitive health: 24% recommended mental activity, 20% healthy diets, 20% physical activity, and 16% social involvement. Among health departments, 30% promoted cognitive health in the same ways. Among senior centers, 21% offered strategies, primarily mental activity. Results suggest emerging activity in this area and opportunities for continued development.

At least 15 million Americans have substantial loss of cognitive function. ¹ The prevalence of cognitive problems increases dramatically with age, ² making this issue increasingly important as life expectancy rises, and as the large baby boom cohort ages. Alzheimer’s disease, a major contributor to rates of cognitive impairment, has surpassed diabetes as a leading cause of death. It is now the fifth leading cause for those aged 65 and older. ² Many adults in the United States are concerned about Alzheimer's disease, memory loss, or other types of cognitive decline and want to reduce their risks for these problems. ^3,4 As baby boomers age, more Americans will seek ways to maintain cognitive health.

There is no single accepted definition of cognitive health. We adopt the definition of a National Institutes of Health report that defines cognitive health as both the absence of disease and “the development and preservation of the multidimensional cognitive structure that allows the older adult to maintain social connectedness, an ongoing sense of purpose, and the abilities to function independently, to permit functional recovery from illness or injury, and to cope with residual functional deficits.”^5(p13) In terms used more commonly by the American public, cognitive health includes the ability to think clearly and remember what is important to us—and to avoid developing Alzheimer’s disease or a related disorder. ⁴

About half of the Americans think that certain behaviors lower the risk of developing Alzheimer's disease. ^3,6 Many older Americans say they believe that physical activity helps maintain cognitive health, although few report having enough physical activity to fulfill established recommendations. ⁷ Many also believe that healthy diets promote cognitive health, ^7,8 along with doing crossword puzzles or other “mind games,” ⁹ taking nutritional supplements, ^7,10 or following advice from family or physicians. ¹¹ Research suggests that the latter advice most often emphasizes the usefulness of mental activity. ¹² An increasing body of research following large groups of people over many years, as well as research with animals, suggests that certain behaviors may help to maintain cognitive health. The behaviors include being physically active, having a heart healthy diet, and being socially involved. ^{5,13 –22}

More research is needed before we can conclude that health behaviors influence cognitive health. ^23,24 However, the evidence was clear enough that the Centers for Disease Control and Prevention (CDC) and the Alzheimer’s Association launched a national effort promoting cognitive health in 2007, the Healthy Brain Initiative. ^25,26 While most researchers in this area acknowledge uncertainty about the benefits of healthy behaviors for cognitive health, a recent CDC report advises “Opportunities for maintaining cognitive health are growing as public health professionals gain a better understanding of cognitive decline risk factors. The public health community should embrace cognitive health as a priority, [and] invest in its promotion.” ²⁷

Until recently, the CDC’s project was largely limited to conducting formative research to better understand public views about cognitive health, ^{4,7 –9,26,28,29} completing a formal review of the scientific literature that may support public health initiatives to promote cognitive health, ³⁰ planning for communications to inform public health departments about promoting cognitive health, ²⁷ and conducting research on health care providers’ beliefs and practices regarding cognitive health. ^11,12 In a recent development, the CDC now offers specific messages to the public about maintaining cognitive health by being physically active and socially involved, having stimulating mental activity, avoiding head injury, avoiding smoking, lowering cholesterol, reducing sodium intake, and limiting alcohol consumption. ³¹

The CDC is also actively working to further promote cognitive health by influencing policy at the federal, state, and local levels. ³² A notable policy effort is the development of the National Plan to Address Alzheimer’s Disease, which includes a strategy to quickly translate research findings into public health practice. ³³ Given these efforts and the increasing volume of scientific studies linking healthy behaviors with cognitive health, it is useful to examine the degree to which organizations serving older adults currently offer information, products, programs, or services promoting cognitive health. Doing so can provide a baseline measurement of activity in this area, which can be used to track the diffusion of this policy innovation.

Theoretical Framework and Policy Context

The theory of agenda setting suggests that popular media influence what people think about and value, in part by focusing public attention on selected issues. ^34,35 Popular media may play an important role in setting priorities for health issues. ³⁵ Developed with a focus on traditional news outlets such as newspapers and television, the theory of agenda setting has been extended to health communication and the Internet. ^{34 –37} Applied to health care and public health, agenda setting suggests that an audience exposed to a health issue with a high level of publicity is more likely to think about that issue, consider it important, and act on it. ³⁴ The theory of agenda setting suggests that it is useful to understand how the public media represent an emerging public health issue such as the promotion of cognitive health, both before and after policy changes designed ultimately to influence public attitudes, beliefs, knowledge, and actions. In the present study we focus on that representation on the Internet.

The CDC is working to fulfill 14 “intermediate goals” focused on promoting cognitive health, first published in 2007. ²⁵ Among them are “increase awareness about the importance of promoting and protecting cognition among the general public, public health and aging professionals, and policy makers”; “increase knowledge about the risk and protective factors associated with cognition among the general public and public health and aging professionals”; and “modify key public and private policies to address cognitive health.”^25(pp26,27) Thus, the Healthy Brain Initiative, which proposed policy and research goals for the nation, is an agenda setting effort intended to change how health departments and other organizations serving aging persons depict cognitive health in their public communications. It is also intended to influence public policy regarding cognitive health at the local, state, and federal levels. ²⁷

Despite this large plan, the Healthy Brain Initiative has included only limited efforts to understand how cognitive health is currently represented in public media, or the degree to which health care organizations, public health organizations, and aging services providers may already promote cognitive health. Although there is evidence that the public often turns to health care providers for information about cognitive health, ¹¹ no study has examined how health care providers represent cognitive health in their public communications, such as their Web sites. Similarly, no research has examined how public health departments or other organizations providing services to older persons represent cognitive health in their public communications.

Study Objectives and Contributions

Our study addressed the following research question: to what extent do major health care systems, public health departments, and senior centers promote cognitive health? Our analysis focused on information available at the Web sites of the organizations we studied. We examined the Web sites for information, products, programs, or services intended to promote cognitive health. To simplify the presentation, from here forward we refer to results in any of those categories as strategies promoting cognitive health.

The present study extends recent research that examined the cognitive health content of popular magazines, ^36,38,39 and the Web sites of 3 leading cable news companies. ³⁷ Our study had 2 principal objectives. The first was to identify the percentages of health care systems, public health departments, and senior centers offering strategies promoting cognitive health on their Web sites. The second was to describe the strategies. We also examined the strategies promoting cognitive health in states, distinguished from plans for the care of people with Alzheimer’s disease or support for their families. Results can provide baseline information for monitoring the progress of the national Healthy Brain Initiative and the portion of the National Plan to Address Alzheimer’s Disease that focuses on public education. Findings also may suggest the degree to which the concept of promoting “cognitive health” is present in the health care marketplace, public health departments, and aging services.

Methods

Overview, Search Strategy, and Search Terms

The first and second authors are gerontologists with substantial research expertise in promoting cognitive health, health services, public health and health communication, and long-term care. The first author was the principal investigator of The Healthy Brain Study, a large 4-year research study conducted in 9 areas of the United States, funded by the CDC. ^{13,25 –27} He also cochaired the Steering Committee of The Healthy Brain Initiative, a collaboration of the CDC and the Alzheimer’s Association that established national goals for promoting cognitive health. ^{13,25 –27} The second author, a coinvestigator in The Healthy Brain Study, has published extensively on promoting cognitive health. ^{4 ,7 –11,28,29,36,38 –41} The third author is an advanced graduate student of both health administration and business administration with training in sociological research methods. The first and second authors provided additional training to the third author in cognitive health promotion, health communication, and research methods.

We conducted an Internet search during February through July of 2011, examining Web sites of 3 types of organizations: major hospital and health care delivery systems, public health departments, and senior centers. We studied state plans for promoting cognitive health during that time as well, and updated that analysis in May 2012. We identified search terms for the Internet search based on recent major public health and research initiatives in cognitive health. ^5,25 The terms also reflected results of research with over 50 focus groups with diverse populations throughout the United States, which included a focus on the terms Americans use when they discuss issues related to cognitive health. ^4,8,9,28,29 All of the authors participated in developing a single set of search criteria and strategies that we used to search the Web sites. While we conducted the search, all authors met weekly to review the results to ensure that the review was comprehensive and valid.

Searches focused on a variety of terms including Alzheimer’s disease; brain or cognitive fitness; brain or cognitive health; brain or cognitive training; cognitive decline; dementia; disease prevention; brain, cognitive, or mental fitness; memory loss; older adults; preventive health; problem solving; resilience; seniors; and successful aging. We included Alzheimer’s disease and dementia in this list despite our focus on promoting cognitive health because these search terms sometimes identified relevant Web sites. We did not examine information about cognitive health that was relevant only to infant or child development. We focused on adult cognitive health.

For all 3 of the organizational types we studied, we examined all relevant pages of each organization’s Web site to identify whether the Web site offered strategies promoting cognitive health. We examined: health care systems with large hospitals; the health departments of all 50 states and the 20 largest US cities, and the 181 senior centers that were nationally accredited when we reviewed the Web sites. ⁴² We examined Web site content for the presence of strategies promoting cognitive health and for links to relevant information sources such as activity calendars, brochures, libraries, posters, or video recordings. To maintain our focus on the promotion of cognitive health, we excluded products and services for treating dementia, such as memory services, memory clinics, or drug therapies. ⁴³ However, we included strategies focused on mild cognitive impairment or other problems with cognitive function if they were offered for secondary prevention of dementia. Although cognitive and emotional health can be closely related, we did not search for strategies promoting emotional health. Our focus on cognitive health was consistent with the Healthy Brain Initiative, which focuses principally on promoting cognitive health. ^25,27

For each Web site for health care systems and hospitals, after using the organization’s internal search engine (when present), we performed an external Google search. Prior to each Google search, we deleted all memory of previous searches from our Web browser to ensure that the order of results presented by each new search would not be influenced by previous searches. For Web sites with many suggestions or links focused on cognitive health, our strategy was to examine them until the results became sufficiently repetitive that the likelihood of finding new information was low. However, few Web sites had many relevant suggestions or links. We limited our search of newsletter archives to the 2 most recent newsletters to ensure that the results measured currently offered strategies promoting cognitive health.

Search Strategy Specific to Hospitals and Health Care Systems

We used the Thomson Reuters’ 2011 list of “100 Top Hospitals” to identify large hospital and health care systems. ⁴⁴ The list includes hospital and health care systems based on risk adjustment for complications, length of stay, mortality, readmission rate, safety problems, and related hospital performance measures. We also included hospitals from Becker’s Hospital Review’s “50 largest nonprofit hospitals in America.” ⁴⁵ We also used hospitals listed on “Becker’s Best Hospitals Honor Roll,” which includes US hospitals with an “extremely high-quality score,” at least 4 standard deviations (SDs) above the mean. ⁴⁶ We used this list of hospitals to ensure that high caliber hospitals were included. We identified 6 hospitals using Becker’s Best Honor Roll that were not included on either Thomson Reuters’ list or Becker’s Review, and included them in our study: Ronald Reagan UCLA Medical Center, University of California San Francisco Medical Center, University of Michigan Hospitals and Health Centers, University of Washington Medical Center, Duke University Medical Center, and Brigham and Women’s Hospital. Thus, we examined the Web sites of 156 health systems.

In addition to using the internal and external search engines, several Web sites included a “services” tab or link, or a similar tab or link such as “programs.” Using these, we examined all content associated with any potentially relevant terms such as adult services, behavioral health, neurology or neurosciences, older adult services, senior services, and specialty services, as well as the search terms listed above. Several of the hospital Web sites included online “health libraries.” These often had basic information about dementia and Alzheimer’s disease but no strategies promoting cognitive health, although some libraries contained such strategies. For the hospital and health system search, we found all relevant results using internal search engines. The external Google searches did not provide additional results.

Search Strategy Specific to Public Health Departments

We also used the search strategy described above to examine the Web sites of state health departments for all 50 states, as well as the health department Web sites of the 20 largest American cities. Thus, we examined 70 public health Web sites. As with the other searches, we examined whether each Web site offered strategies promoting cognitive health. Web sites with links to materials of this type, such as the Alzheimer’s Association’s Maintain Your Brain program, were considered to include such information. More general links to organizations such as the Alzheimer’s Association were not considered to offer strategies promoting cognitive health if there was no mention of promoting cognitive health or preventing memory loss.

Search Strategy Specific to Senior Centers

We also used the search strategies described above to examine the Web sites of 181 accredited senior centers. ⁴² According to the National Council on Aging’s Web site, these accredited senior centers serve an average of 3700 older adults each year, with an average daily attendance of 200. ⁴²

Data Analysis

Variables in our database included organization name, organization geographic location, Web site access date, URL (Web site Internet address), and a narrative description of the Web site focusing on strategies promoting cognitive health. We also summarized any special features of cognitive health promotion that might make the Web site stand out among the others. We examined each Web site for the presence of 13 variables representing specific strategies for promoting cognitive health. Nine of these indicated whether each Web site had specific information about preventing cognitive decline or memory loss; preventing further decline for those already affected by cognitive impairment; diet or nutrition and cognitive health; physical activity and cognitive health; mental activity and cognitive health; social involvement and cognitive health; use of technology for cognitive health; availability of information or services about cognitive health; and availability of cognitive health strategies for sale.

The 10th strategy variable indicated whether each state had a formal written plan to address Alzheimer’s disease, and whether that plan included any explicit focus on promoting cognitive health. The 11th, 12th, and 13th strategy variables indicated whether a given Web site included relevant strategies for special populations such as African Americans or Hispanics; whether drugs were suggested for cognitive health; and whether any alternative medicines, herbs, medical foods or vitamins, or other substances were recommended for this purpose. We were mindful that Web sites might use descriptions or terms or offer relevant strategies, that we did not anticipate when we developed the variable list.

The third author reviewed the Web sites. To assure coding accuracy, the first and second authors each independently reviewed 20% of the Web sites in each of the 3 categories (health care systems, public health departments, senior centers). Consistent with epidemiological studies involving professional judgments about the presence of variables in data, we assumed that the consensus judgment of the first and second authors was the “gold standard” for evaluating the third author’s coding. Interrater agreement exceeded 95%. We discussed the rare instances when we disagreed about the presence of a strategy until we reached consensus. We used descriptive statistics to examine the strategy frequencies.

Results

Table 1 identifies and defines the strategies for promoting cognitive health that we examined, provides examples of each strategy, and reports results for selected strategies. Only 5 of the 13 strategies appeared with substantial frequency. Table 1 shows the 5 strategies: nutrition, physical activity, mental activity, social involvement, and strategies for avoiding further cognitive decline for individuals with cognitive impairment. The remaining 8 strategies, found with limited frequency, are represented in the summary results shown in the first data row of Table 1, labeled Any Strategy. Examples of strategies found with limited frequency include recommendations to use drugs to prevent cognitive decline, recommendations to use herbs such as ginseng or alternative medicines for that purpose, and recommendations to use computers or software to enhance cognitive function.

Table 1.

Strategies Promoting Cognitive Health in Websites of Health Care Systems with Large Hospitals, Public Health Departments, and Nationally Accredited Senior Centers^a

Strategy	Category definitions and examplesb	Health care systems (n = 156) %	Public health departments (n = 70) %	Senior centers (n = 181) %
Any strategy	Web site includes any category below, or one or more strategies found with low frequency, including stopping smoking, avoiding head injury (eg, using seat belts, reducing fall risks in the home), playing computer games for cognitive health, taking drugs or vitamins, reducing stress, using or avoiding estrogen replacement, adjusting blood homocysteine	40.0	30.0	21.0
Nutrition	Strategies typically emphasizing heart healthy diets for cognitive health, including consuming fruits, vegetables, olive oil, fish, whole grains and nuts, or advising avoidance of foods with unhealthy fats, high sodium content, or other risks to vascular health, or that may contribute to overweight or obesity, hypertension, or diabetes	20.4	18.1	1.7
Physical activity	Strategies emphasizing regular physical activity for cognitive health, as well as those emphasizing that physical inactivity contributes to diabetes and hypertension, which can adversely affect cognitive health. Physical activities included exercise, weight training, and leisure-time physical activities such as gardening, dancing, and walking	20.4	18.1	2.8
Mental activity	Strategies focused on mental activities for cognitive health, such as reading, playing a musical instrument, studying a new language, learning new knowledge, playing games or completing puzzles	23.6	16.7	12.8
Social involvement	Strategies emphasizing group activities and socializing with others for cognitive health	15.9	30.6	2.8
Strategies for those with existing cognitive impairment	Category could include any of the strategies above for those with cognitive impairment, where the purpose was to improve cognitive function or avoid further cognitive decline. Drug therapies for cognitive impairment, or Alzheimer’s disease or other dementias were not included in this category	5.7	5.6	0

^a Numbers in the table indicate the percentage of the Web sites within each organizational type with each characteristic; we defined “strategies promoting cognitive health” as the presence of information, products, programs, or services promoting cognitive health, excluding materials regarding the diagnosis or treatment of dementia or other forms of cognitive impairment.

^b In all categories, strategies with little or no support in scientific literature (eg, use of ginseng for cognitive health) were considered to fulfill the search criteria; except as noted in the text, such strategies appeared rarely.

Hospitals and Health Care Systems

As Table 1 shows, 40% of health care systems offered strategies promoting cognitive health. Of all health care systems, 24% recommended mental activity for cognitive health, 20% healthy diets, 20% physical activity, and 16% social involvement.

The amount of material promoting cognitive health ranged from no information to strategies specifically intended to reduce memory loss. An example of the latter was at the Web site of Rush University Medical Center, in Chicago, which offered a service called Maximizing Your Memory. ⁴⁷ The UCLA Longevity Center offered a Brain Bootcamp class and a memory training center focused on preventing cognitive decline. ⁴⁸ The Mayo Clinic featured the “Live Well. Think Well” program to address the possible greater risk of cognitive decline among African Americans and suggested ways to promote cognitive health. ⁴⁹ However, only a few Web sites commented that minority populations might have higher risks for cognitive decline.

Public Health Departments

Among public health departments, 30% offered strategies promoting cognitive health. All of those recommended social involvement. Of all state health departments, 25% recommended physical activity for cognitive health, 18% diet, 17% mental activity, and only 1% drugs or products (data not shown in the table). In Alaska, where the number of older persons is growing at 4 times the national average, ⁵⁰ the state’s Commission on Aging launched a “Healthy Body, Healthy Aging” campaign in 2007. ⁵¹ The campaign is an outreach effort for baby boomers and older adults, focused on senior centers and public health centers. It promotes physical activity, “smart eating,” mental challenges, group activities, and “fun with others!” with the headline, “Make choices for a healthier future! Participating in these activities may protect your brain against the risk of Alzheimer’s Disease and Related Dementia.” ⁵¹ The program focuses on health behaviors and “reducing risk for developing Alzheimer’s disease and related dementias” through mental activity, physical activity, healthy diets, “being positive and socializing”, living tobacco free, and reducing medical risks including heart disease, stroke, high blood pressure, high cholesterol levels, diabetes, and head injuries. ⁵¹

In all, 23 states had links to comprehensive plans for Alzheimer’s disease, 9 of which included strategies promoting cognitive health. The Alzheimer’s Association maintains a comparison of these state plans, including a comparison specifically focused on “brain health.” ⁵² For example, the Massachusetts State Plan briefly reviews evidence associating cognitive decline with high cholesterol, type 2 diabetes, high blood pressure, physical inactivity, smoking and obesity, and lack of social connectedness, and provides citations to the scientific literature supporting that discussion. ⁵³ It also observes, “Diets that include relatively little red meat and emphasize whole grains, fruits and vegetables, fish, shellfish, nuts, olive oil and other healthy fats, may also improve cardiovascular and brain health,” again providing a citation to the scientific literature. ⁵³ The document concludes, “While none of these lifestyle changes will eliminate the possibility of getting Alzheimer's, continued and expanded public education efforts regarding the potential of a healthy, active lifestyle could delay the onset and reduce the severity of symptoms for thousands of individuals.” ⁵³ The Maryland Department of Health and Mental Hygiene similarly suggested that physical activity and healthy diets may promote cognitive health. ⁵⁴ It added, in an Issue Brief on this subject, “There may be a link between head trauma and risk of Alzheimer’s disease. Protect your brain by wearing a helmet while playing sports, buckling your seatbelt, and fall proofing your home.” ⁵⁴ It also recommended, “Keep Your Mind Active: Research suggests that staying mentally active may help to preserve cognitive functioning. Reading challenging books, learning a musical instrument, studying a new language will build cognitive reserves and may slow symptoms of dementia.” ⁵⁴ There were no citations provided to support these recommendations. Arkansas’s plan noted, “Some data indicate that management of cardiovascular risk factors, such as high cholesterol, type 2 diabetes, high blood pressure, smoking, obesity, and physical inactivity may help avoid or delay cognitive decline.” ⁵⁵

In most instances, descriptions of prevention in these state plans were brief. The plans focused principally on issues affecting individuals with Alzheimer’s disease and their families, and on policy issues for governments. California’s plan, for example, says only, “Coordinate with organizations that are actively working to reduce risk factors such as diabetes and heart disease to promote disease prevention and brain health.” ⁵⁶ The California plan also includes a strategy of “promoting brain health initiatives to reduce risk factors, especially in ethnically diverse communities.” ⁵⁶ Oklahoma’s state plan for Alzheimer’s disease says, “Scientists consider the emerging field of prevention among the most exciting recent developments in the dementia research arena.” ⁵⁷ The plan includes a recommendation for employee education: “Addressing brain health in the work force can minimize absence due to preventable illness.” ⁵⁷ South Carolina’s plan is uniquely specific in presenting “10 Ways to Maintain Your Brain,” a list developed by the Alzheimer’s Association for its Maintain Your Brain program. ⁵⁸

Senior Centers

Among senior centers, 21% offered strategies promoting cognitive health, 13% specifically advised mental activity, 3% social involvement, 3% physical activity, and 2% healthy diets. Strategies included “drum therapy”; workshops or “brain games” such as “maximizing your memory,” “brain boosters,” and “cranium crunch”; participating in memory games and tongue twisters; and using computer programs for brain fitness. None of the Web sites mentioned use of drugs, nutritional supplements, or other products for cognitive health.

Exemplifying services, Avenidas Senior Center in Palo Alto, California, offered classes with bridge instruction and a book club, both promoted for “Brain Fitness” and a demonstration of “how playing the harmonica improves brain and body fitness”; an invitation to “experience the ‘Mozart Effect’ with music to enhance creativity, healing, and brain fitness”; and an invitation to participate in improvisation: “It’s fun and good for your brain!” ⁵⁹ The Web site indicates that Avenidas collaborates with the Alzheimer’s Association to offer the “Maintain Your Brain” program, a 1-hour workshop on “simple changes leading to a brain-healthy lifestyle.” ⁵⁹ The description says the program tells participants “how to make smart nutritional choices and reduce risk of brain diseases.” ⁵⁹

Some resources described at senior center Web sites were focused on certain groups. For example, the Center in the Park, in Philadelphia, offered a program to improve the mental health of African American older adults. ⁶⁰ The program, called “In Touch,” was based on West African traditions and sought “to understand and support healthy aging of the Mind, Body & Spirit of older African Americans through research, education and evidence based service programming.” ⁶⁰

Discussion

This was the first study to examine strategies for promoting cognitive health on the Web sites of health care systems, public health departments, and senior centers. About 40% of health care systems and 30% of public health departments recommended such strategies. Recommendations most frequently focused on mental activity, healthy diets, physical activity, and social involvement. A smaller percentage of senior center Web sites (21%) offered such strategies.

Recommendations were generally consistent with the growing science base suggesting that physical activity, diet, social involvement, and possibly mental activity may help to maintain cognitive health. ^{5,13 –22} Currently the strongest evidence may be that physical activity helps to do so. ^{14 –18} Yet only about 20% of health systems, 18% of public health departments, and less than 3% of accredited senior centers mentioned physical activity as a strategy for cognitive health.

The theory of agenda-setting suggests that the media promote selected health-related topics and behaviors, and that this tends to focus public attention on these topics and behaviors. ^34,35 Our results suggest the public may already receive some information about promoting cognitive health from health care systems, public health departments, and senior centers. This information may influence perceptions and attitudes, and possibly behavior. However, to encounter this information, an individual must visit these Web sites. Given the percentage of organizations that offered strategies promoting cognitive health, an individual would likely need to visit more than one of them to encounter this information. Our results suggest that the diffusion of information about cognitive health is currently limited in the organizations we studied, although there are other Web sites and other media that offer such strategies. ^{36 –39}

Recommendations about cognitive health were more common in the Web sites we studied than in popular magazines published during 2006 to 2007, which had only limited coverage of cognitive health. ^36,38,39 This difference may be due, in part, to increased publicity about cognitive health during the past 5 years. Results may also be due to our study’s focus on health care organizations, medical care, and public health and wellness; previous studies examined cognitive health content of popular magazines focused on other topics.

Our study had several limitations. Using independent judges who are blind to the study’s aim might limit bias. However, it is common in health communication research for those who design a study to participate in the data collection. Bias should be limited by the fact that we evaluated the Web sites for the presence of strategies, rather than judging their value or scientific accuracy.

The health care systems we studied were among the largest and most successful in the United States. Health care systems with this size and success are likely to have practices in relevant specialties including behavioral health, geriatrics, neurology, psychiatry, and psychology. They also may have researchers whose work focuses on understanding cognitive health as well as greater administrative resources for developing new programs and marketing them on Web sites. Clinicians in these practices may be more likely than those in smaller health care systems to be aware of the increasing evidence associating health behaviors with cognitive health. The results may not represent developments in smaller health care systems, where evidence suggests that general practitioners and internists may have limited knowledge about promoting cognitive health and may find it difficult to keep current in this area. ¹²

Similarly, the nationally accredited senior centers we studied may not be representative of the approximately 11 000 senior centers in the United States. Accreditation typically requires 6 to 12 months of professional effort, an accreditation fee, peer review expenses, and optional expenses for technical assistance. ⁶¹ Accredited senior centers may have more resources than others and may differ in cognitive health promotion. The public health departments included all 50 states; the cities were limited to the 20 largest in the United States. A formal text analysis of cognitive health content could extend this research; however, relevant text at most Web sites was limited. Other extensions could identify how health care systems treat promoting cognitive health as an area for revenue growth, or the degree to which cognitive decline and Alzheimer’s disease is depicted as “preventable” illness. As strategies promoting cognitive health become increasingly common in popular media, a need may grow for communications designed to counter stigma and guilt for individuals and families affected by Alzheimer’s disease and related disorders. Healthy behaviors cannot prevent every instance of these diseases. Yet increasing media attention in this area may convey that damaging impression, reinforcing stigma associated with these diseases.

The national agenda established by the Healthy Brain Initiative ^25,27,31,32 and the national goal to rapidly inform the public about new scientific advances in this area ³³ suggest that the American public may soon receive more messages about maintaining cognitive health. As our results suggest, such messages are already beginning to appear. In public health practice, states like Alaska may be on the forefront of efforts to promote cognitive health. Given the national policy agenda, future studies may find that more health systems, public health departments, and senior centers promote cognitive health. Our results provide a baseline measure of cognitive health promotion, one that should be useful for understanding the growth of this new public health agenda. Promoting cognitive health is also potentially a new source of revenue for health care systems, and a way for senior centers to attract and retain clients. Moreover, the concern about maintaining cognitive function among baby boomers suggests there may be growing demand for strategies promoting cognitive health as that large cohort ages. These developments suggest that it will be useful to monitor the growth of health promotion efforts focused on cognitive health.