J Neurol (2006) 253 : 307315

DOI 10.1007/s00415-005-0986-6 ORI GI NAL COMMUNI CATI ON

Nir Giladi
Michael Mordechovich
Leor Gruendlinger
Herzel Shabtai
Doron Merims
Simona Naor
Rositsa Baltadzhieva
Jeffrey M. Hausdorff
Alexander Y. Gur
Natan M. Bornstein
Brain Screen
A self-referral, screening program for strokes,
falls and dementia risk factors
Introduction
Strokes, falls and dementias are the leading causes for
functional deterioration, loss of independence and in-
stitutionalization of elderly people. Those common dis-
orders are the end results of slowly progressive brain
dysfunction after a long pre-clinical phase. Motor and
cognitive brain disorders can be attributed to many
known risk factors that can be modified.
Early detection of risk factors for strokes, falls and
dementia is justified only if interventional program can
modify the natural history of the screened disturbances.
Stroke risk has been shown to be modified by better pre-
vention of cardiac embolism, slowing atherosclerosis or
treating carotid stenosis [6]. Falls risk can be modified
J
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Received: 16 March 2005
Received in revised form: 29 June 2005
Accepted: 13 July 2005
Published online: 10 October 2005
N. Giladi, MD () M. Mordechovich, MD
L. Gruendlinger, BSc H. Shabtai, MD
D. Merims, MD R. Baltadzhieva, MD
J. M. Hausdorff, PhD A. Y. Gur, MD, PhD
N. M. Bornstein, MD
Movement Disorders Unit
Department of Neurology
Tel-Aviv Sourasky Medical Center
6 Weizman Street
Tel-Aviv 64239, Israel
Tel.: +972-3/6974912
Fax: +972-3/6974911
E-Mail: ngiladi@ tasmc.health.gov.il
N. Giladi, MD D. Merims, MD
J. M. Hausdorff, PhD A. Y. Gur, MD, PhD
N. M. Bornstein, MD
Sackler Faculty of Medicine
Tel-Aviv University
Tel-Aviv, Israel
S. Naor, MD
Outpatient Psychiatric Clinic
Kaplan Medical Center
Rehovot
Hadassa School of Medicine
Hebrew University
Jerusalem, Israel
Abstract Background Falls,
strokes and dementia can be
predicted and their occurrence
can be delayed or even prevented
by treatment of risk factors. The
value of screening self-referred
adults is unknown. Objectives To
assess whether a screening pro-
gram of self-referred adults pro-
vides new and valuable medical
information on risk factors for
falls, stroke and dementia. Method
We examined 514 self-referred
people (59% women, mean age
688 years (range 4489) and
143 years of education) in our
Brain Screen program. Partici-
pants completed detailed question-
naires and underwent a neurologi-
cal examination, computerized gait
analysis, carotid Duplex, serum
lipid and homocysteine levels, a
computerized neuropsychological
battery (NeuroTrax) and the
Mini-Mental State Exam. Informa-
tion that was detected by Brain
Screen was compared with the
self-reported data. Results Un-
known vascular risk factors de-
tected by Brain Screen included:
high cholesterol in 44%, homocys-
teine >10 mol/L in 20%, >1mm
carotid intima-media thickness in
13%, and carotid narrowing
(>30%) in 2.2%. Unknown risk
factors for falls were detected in
66% of the subjects who never fell.
Of the 205 subjects (44%) who
complained of memory decline,
28% had objective memory
disturbances compared with
their age group. Mild cognitive
impairment (amnestic MCI) was
clinically diagnosed in 17% of the
population and dementia in 5%.
Conclusion Screening self-referred
adults for falls, strokes and demen-
tia risk factors detected significant
unknown risk factors that can be
treated in more than one-third of
the participants. A national Brain
Screen program can have signifi-
cant impact on the health of the
aging population.
Key words risk factor
prevention stroke dementia fall
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308
by increasing the awareness, adjusting home conditions
as well as by maintaining physical fitness, visual acuity,
decreasing the number of medications taken, or im-
proving alertness and mood [12]. The onset of demen-
tia can be delayed by intellectual stimulation and in-
creasing leisure activity [39], better control of risk
factors for atherosclerosis [37], and possibly by lowering
the homocystein level [32], treating depression and de-
creasing inflammatory process reflected by high level of
C-reactive protein (CRP) [30].
On 1 February 2003, the Department of Neurology of
Tel-Aviv Sourasky Medical Center initiated a unique
screening program called Brain Screen for the general
elderly population. This program provides information
on risk factors for stroke, falls and dementia to the gen-
eral elderly population of the entire country. Individuals
receive questionnaires to fill out at home and are sched-
uled for assessment at the Medical Center. A summary of
the results, the risk factor profile and practical recom-
mendations how to decrease their risk are given at the
return visit.
We now report on the first 514 consecutive people
who participated in Brain Screen. In addition, we
assessed whether the information imparted to the
screened population was of any significance in terms of
new findings which could either be modified or affect
the persons life style.
Methods
General setup
Brain Screenis a self-referral, self paid, screening program available
to the general population over 50 years of age. It has been advertised
in the countrys electronic and print media, and most of the people
who enlisted had learned about it from national newspapers. Those
who approach Brain Screen and have not been diagnosed with
Alzheimers disease, Parkinsons disease, or have a history of major
stroke with significant motor or cognitive deficit, major head trauma
or any chronic neurological disorders, receive by mail a questionnaire
to be self-answered with the help of family members and the family
physician.
The self-reported questionnaires include:
General information: This section covers demographic and de-
tailed past and present medical information as well as a detailed
family history for neurological disorders and atherosclerotic car-
diovascular diseases. Other questions concern past and present
depression, sleep problems and change in body weight. A signifi-
cant part of the questionnaire contains a set of questions about
general cognitive performance, the presence of memory disturb-
ances, language and reading difficulties, orientation in space,
and the use of household appliances. Finally, there are specific
questions for assessing the time course of any difficulty and its
effect on daily activities.
Fall history questionnaire for assessing fall frequency over the
past week and 1, 6, 12 and 24 months.
Instrumental Activities of Daily Living (IADL) questionnaire [21].
Questionnaire about leisure time activities during the last month.
Short Geriatric Depression Scale (GDS) questionnaire [33].
Spielberger Anxiety Scale questionnaire [34].
First Visit Agenda
Checking the self-answered questionnaires and completing any
missing information.
Full neurological examination by a certified neurologist, includ-
ing detailed assessment of mental and cognitive activities of daily
life.
Measuring supine (after 3 minutes) and standing (after 2 minutes)
blood pressure.
Calculating body mass index (BMI; in kg/m
2
)
Performing the Mini-Mental State Exam [10] (MMSE) by a neu-
rologist.
Assessment of balance and postural control:
Measured (seconds) tandem stand for up to 30 seconds
Timed Up-and Go test (getting up from a chair, walking for 3
meters, turning around, walking back and sitting on the same
chair) [25]
Pull test [9]
Gait speed walking for 20 meters at a self-determined, comfor-
table pace.
Gait dynamics: walking for 2 minutes in a corridor of 25 meters length
and 2 meters width, while wearing force-sensitive insoles that en-
able the determination of gait cycle timing (e. g.: stride time) on a
stride-to-stride basis [15]. The coefficient of variation (CV) of the
stride time was determined by a method that quantifies the dy-
namics of walking and filters outliers(due to turns) [16, 19]. The
CV of locomotion assesses stride-to-stride variability or gait dys-
rhythmicity, a measure associated with fall risk [16].
Computerized neuropsychological test, which takes about 40 minutes
(NeuroTrax Inc) [7, 8, 31]. The battery includes tests for memory, ex-
ecutive functions, spatial orientation, concentration and motor skills.
The memory battery includes accuracy assessment of verbal memory,
delayed verbal memory, non-verbal memory and delayed non-verbal
memory. All scores are normalized, 100 is the mean and 1 SD is 15
points for matched ages and education levels. This computerized bat-
tery has recently been reported to be practical for neuropsychologi-
cal assessment of non-demented older adults [17].
Carotid Duplex (Acuson 128 XP Flash/10) measuring Intima-
media wall thickness (IMT) and the presence of atherosclerotic
plaques or stenosis of the internal carotid arteries.
Blood tests are done after fasting for 12 hours:
Total cholesterol, high-density lipoprotein cholesterol (HDL-c),
low-density lipoprotein cholesterol (LDL-c), triglycerides, urea
Homocysteine
High sensitive C-reactive protein (CRP)
Complete blood count (CBC)
Second Visit Agenda
At this visit a certified neurologist or psychogeriatrician discusses
with the subject any risk factors for stroke, falls or cognitive decline
that had been revealed. The session ends with a detailed explanation
of the Brain Screens recommendations what should be done in or-
der to prevent or delay stroke, falls or dementia. All results and rec-
ommendations are given in writing in order to be discussed with the
primary family doctor. Fig. 1 displays the general setup (Brain Screen
protocol)
Discovery of new and unknown risk factors
Risk factors for stroke
Known risk factors were taken from the history as given by the indi-
vidual. Unknown high total cholesterol (>200mg%), high LDL-c
(>130mg%), high plasma homocysteine (10mol/L), high CRP
(>3mg/L), carotid stenosis (>30%) or a thickened IMT (1mm)
were considered as significant vascular risk factors discovered by
Brain Screen.
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309
Risk factors for falls
A subject was considered as having a positive history of falls and,
therefore, to have a known risk of future falling if he/she reported at
least one fall during the last previous year [12]. An increased risk of
fall was defined by the observation of any of the following: 1. Timed
Up-and-Go time >13.5 seconds, 2. tandem stance <20 seconds, 3. in-
ability to maintain balance in response to the pull test [9] (pull
test 2), 4. stride time coefficient of variation (CV) 2.5%, 5. >5
points on the short Geriatric Depression Scale (GDS) questionnaire,
6. MMSE<25, or 7. signs of parkinsonism, i. e., if a subject had rest
tremor and either rigidity or abnormal postural response (pull
test 2). New risk factors for falls were considered to be discovered by
Brain Screen if a risk factor was detected and the subject did not
have a history of falls, or known and treated parkinsonism.
Risk factors for dementia
We considered a risk factor for dementia as being newly discovered
only if a person was diagnosed as having amnestic MCI (see below)
or the MMSE score was <25/30. Patients with known dementia when
entering the Brain Screen program or with dementia diagnosed by
Brain Screenwere excluded from the statistical assessment. Amnes-
tic MCI was diagnosed if a person had a low memory score (<85);
more than 1 standard deviation from the expected performance ad-
justed to age, on the age adjusted NeuroTrax memory subscore and
if he/she self-reported functionally significant memory decline, pro-
gressing over the last year, in the home completed questionnaire. In
addition, the screened diagnosis of amnestic MCI had to be con-
firmed clinically by an experienced neurologist based on the initial
interview, the neurological exam and the objective cognitive assess-
ment. Dementia was diagnosed according to the DSM IV criteria [2].
Even though it is known as a risk factor for stroke and dementia
[13], obesity as measured by body mass index (BMI) was not consid-
ered as a newly discovered risk factor by Brain Screen based on the
assumption that everyone knows if he/she is overweight. We did, how-
ever, relay the information to 347 (68.2%) people and some subjects
were surprised to know that they have a BMI >25. Similarly, in spite
of measuring high blood pressure (>130/>85), we did not consider it
as newly diagnosed risk factor in 329 people, based on the published
criteria, which required more than a single measurement in order to
diagnose high blood pressure [5]. Those whose blood pressure values
were high during Brain Screen and were not aware of their possible
risk (unknown and untreated BP n=169) did, however, benefit from
receiving the information.
Statistics
Results are reported as mean standard deviation. Out-
come, dependent variables were checked for normality
and outliers. Initially, scatter plots and box plots were to
visualize the association between dependent and inde-
pendent variables. Subjects groups were compared us-
ing Fishers exact test and Chi square analysis for cate-
gorical data. For continuous data, the two-sample,
Students t-test was used to compare two groups. A p-
value less than 0.05 (two-tailed) was considered statisti-
cally significant. Statistical analysis was performed us-
ing SPSS for Windows (version 10.1).
Results
The general characteristics of the first consecutive 514
subjects assessed in Brain Screen are presented in
Table 1. In general, the typical screened person was a
woman, around 70 years of age, with 14 years of educa-
tion, overweight, and concerned about memory.
Vascular risk factors (Table 2)
The most significant new finding in terms of vascular
risk factors for stroke was hypercholesterolemia discov-
ered in 203 people (43.8%). Overall, 72.2% of the
screened subjects had hypercholesterolemia, making it
the most common vascular risk factor. Ninety people
Pre-visit one
SeIf reported questionnaires:
GeneraI medicaI & IADL
FaIIs history
Short Geriatric Depression ScaIe
SpieIberger anxiety scaIe
Leisure activities
Visit one - tests
NeuroIogicaI exam
Measuring BMI
Supine and standing bIood pressure
MMSE
BaIance and posturaI controI
Computerized gait dynamics
Computerized neuropsychoIogicaI test
Carotid DoppIer (fIow and IMT)
BIood tests
Last visit
Report on aII tests done
GeneraI risk for:
stroke
faIIs
dementia
PracticaI recommendations
Fig. 1 Brain Screen Protocol (MMSE Mini-Mental
State Exam; IADL Instrumental Activities of daily liv-
ing; BMI Body Mass Index; IMT Intima-media thick-
ness)
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310
(19.9%) were found to have relatively high homocys-
teine (>10mol/L) levels. Interestingly, none of the peo-
ple assessed had reported about hyper-homocystinemia
when they enrolled in Brain Screen, even though this test
is available in all primary care programs in Israel. We did
not find a single person with >50% narrowing of the
carotid arteries and no one in the study cohort had
carotid-related symptoms. IMT measurements of the
carotid artery were not available elsewhere in Israel; so
all-60 persons (13%) with1mm of IMT in one com-
mon carotid artery could not have these data prior to
Brain Screen assessment. CRP is not measured rou-
tinely in Israel, so all-76/218 people with CRP>3mg/L
(34.9%) were not likely to have this information prior to
Brain Screen.
Risk factors for falls (Table 3)
Over one-fifth (105, 22.6%) of the screened population
not including 7 treated parkinsonian patients, reported
at least one fall over the last year. Among them, 82
(78.1%) had at least a second objective risk factor for
falls, 50 (47.6%) had at least two additional risk factors
and 29 (27.6%) had at least three additional risk factors.
Among the 360 people with no history of falls, 239
(66.4%) had at least one objective risk factor for future
falls, 92 (25.6%) had 2 risk factors and 31 (8.6%) had
three risk factors. Among the subjects with no history of
falls, the most common fall risk factors were depressive
signs, poor tandem stance, increased stride CV, and poor
response to the pull test.
One-hundred and two people (22.6%) not including
Table 1 General characteristics of 514 people screened by the Brain Screen pro-
gram
Male/Female (%) 209/305 (40.7/59.3)
Mean age (years) 688 (4489)
Mean years of education 14.03.4
People with body mass index 25 (%) 347 (68.2%)
History of hypertension 198 (42.2%)
History of hypercholesterolemia 183 (39.0%)
History of ischemic heart disease 61 (13.0%)
History of diabetes mellitus 60 (12.8%)
Smokers 50 (10.7%)
History of depression/non-treated (%) 139 (29.6%)/89 (19.0%)
Known and treated parkinsonism 7 (1.4%)
Reasons for participating in Brain Screen*
Memory problems 270 (57.6%)
Stroke concern 23 (4.9%)
Gait insecurity fear of falling 77 (16.4%)
Family history of Alzheimers disease 96 (20.5%)
Other 124 (26.4%)
* A person could have more than one reason
Vascular risk factors Known by history Found by Newly diagnosed by
Brain Screen Brain Screen
Hypercholesterolemia 183 (39 %) 335 (72.2%) 203 (43.8%)
Carotid stenosis (> 30 %) None 10 (2.2%) 10 (2.2%)
IMT 1 mm None 60 (13.0%) 60 (13.0%)
High homocysteine ( 10 mol/L) None 90 (19.9%) 90 (19.9%)
High CRP (> 3 mg/L) (n = 218) None 76 (34.9%) 76 (34.9%)
IMT intima- media thickness; CRP C-reactive protein
* % of total population
Table 2 Frequency* of vascular risk factors pre-
screening and post-Brain Screen
Fall risk factors History of 1 fall Found by No history of falls
over the last year Brain Screen (n = 360, 77.4%)
(n = 105, 22.6%)
TUaG > 13.5 sec 11 (10.5%) 23 12 (3.3%)
Stride-to-stride variability CV 2.5 % 30 (28.6%) 102 72 (20.0%)
Pull test 2 34 (32.4%) 97 63 (17.5%)
Tandem stand < 20 sec 39 (37.1%) 143 104 (28.9%)
MMSE < 25/30 5 (4.8%) 13 8 (2.2%)
Self-reported depression or GDS short > 5 59 (56.2%) 182 123 (34.2%)
Undiagnosed parkinsonism 1 (1.0%) 12 11 (3.1%)
TUaG Timed Up and Go test; CV Coefficient of Variance; MMSE Mini-Mental State Exam; GDS Geriatric depression
scale
Table 3 Detection of risk factors for falls pre- and
post-Brain Screen program
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treated parkinsonian patients had increased stride-to-
stride variability (stride CV 2.5%) and 72 of them had
no history of falls. Interestingly, these 72 subjects with
dysrhythmic locomotion (and no history of falls) had
higher BMI (28.6 vs. 27.3, P<0.05) and a higher average
left common carotid artery IMT (0.65 vs. 0.60, P<0.05)
than the rest of the study cohort. The two groups were
not different with respect to age, history of high blood
pressure, diabetes mellitus, depression (GDS>5) or the
global score on the neuropsychological assessment bat-
tery.
As shown in Table 1, 74 people (16%) not including
treated parkinsonian patients, out of 469 who answered
a question about a cause of approaching Brain Screen,
came because of concerns about gait. Among them,
(93%) had at least one objective risk factor for falls,
(66.2%) had at least 2 risk factors, and 37.8% had at least
3 factors. Among the remaining subjects, 64.8% had at
least one objective risk factor for falls, 24.2% had at least
two risk factors, and 8.5% had at least three risk factors.
Risk factors for cognitive decline (Table 4)
Twenty-two people (4.8%) were diagnosed by Brain
Screen as having dementia. Four of those 22 patients
had already been diagnosed and treated for AD but did
not report about it in the telephone interview. All 22 sub-
jects had been encouraged to contact Brain Screen by
their family members. Only 12/18 of the patients actu-
ally complained about memory loss. Subjective com-
plaint of memory impairment was reported by 351 sub-
jects out of 457 (79.4%) not including the demented
patients. 205 people out of 469 (43.7%) complained
about one year or more of progressive decline in mem-
ory disturbances. Fifty eight out of 444 people who had
reported about their memory and its time course were
diagnosed by Brain Screen as having amnestic MCI,
based on the neuropsychological assessment and the
subjective progressive complaint. Among the 58 Brain
Screen diagnosed Amnestic MCI people 12 were later
diagnosed for the first time as demented by a neurolo-
gist.
The subjects with objective memory impairment
(NeuroTrax memory score <85, n=122) were older
(mean age 71 vs. 66 years, P<0.001) and had higher GDS
scores (4.4 vs. 2.5, P<0.02).
Among the subjects without objective memory im-
pairment (NeuroTrax memory score >85, n=392),
complainers of memory decline had a higher score on
the GDS (3.8 vs. 2.6, P<0.02). Thus, there may be a rela-
tionship between complaining about memory decline
and depression as reflected in the GDS. We could not
demonstrate any relationships between complaining
about memory decline and age to suggest that depres-
sion is the leading factor for complaints about memory
decline.
Discussion
Brain Screen is the first screening program in Israel
which provides data on risk factors for stroke, falls and
dementia. Such a program is justified if it provides new
and valuable information that can be translated into tak-
ing steps which will modify disease course. In order to
provide new and important data, we performed tests
that are not available in any health plan in Israel for
screening purposes. This approach has given a signifi-
cant number of people important and new information
that if treated can modify the risk for stroke, falls or de-
mentia. In order to achieve this goal we had to go over a
very high bar, because such a self-referral population
that took part in the screening program have a high level
of awareness about their health in general and brain dis-
orders in particular, and providing them with new med-
ical information about themselves is not a trivial matter.
The relatively high mean years of education (14.13.4)
in our assessed population, which was much higher than
the mean years of education (9.4) in the general adult
population of that age group in Israel [20], supports this
point. In spite of the good national health plan in Israel,
which covers all Israeli citizens and the relatively well-
educated people who approached Brain Screenduring
the programs initial phase, we were surprised to iden-
tify a high percentage of participants who were com-
pletely unaware of some important and treatable risk
factors.
Cognitive Subjects without subjective Subjects with subjective complaints
assessment tools complaints of memory of progressive memory
disturbances disturbances over the past year
n = 351 (79.4%) n = 205 (43.7%)
MMSE < 25/30 6 7
NeuroTrax Memory
subscore < 85 64 58*
n = 122
* Patients with calculated amnestic-mild cognitive impairment (A-MCI)
Table 4 Frequency of mental disturbances and
comparison between subjective and objective data
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Vascular risk factors
The most striking and unexpected finding was the high
percentage of people who were first informed by Brain
Screen about their hypercholesterolemia. Treatment
with statins for hypercholesterolemia can significantly
decrease the relative and absolute risk for stroke by 21%
and 0.9%, respectively [1]. In spite of the fact that today,
lowering cholesterol level with statins is not considered
as primary but only as secondary stroke prevention, we
believe that treating cardio-vascular risk factors is of
great importance to brain protection. In addition, we
were able to stress the need for follow-up even to those
people who were on statins but were not effectively con-
trolled.
All 58 people who had a 10mg/L concentration of
homocysteine in their plasma were instructed to take
folic acid >1mg/day. Some but not all clinical trials sug-
gest that lowering plasma homocysteine level can de-
crease the risk of stroke [3] and myocardial infarction
[36]. We think all those participants who were informed
that their homocysteine blood level was high, gained
significant and valuable knowledge, first by the aware-
ness of an existing problem and second by initiating
treatment with folic acid, which might have a protective
effect.
The information on IMT and carotid flow has two
major objectives. The first is to increase awareness of the
concept of atherosclerosis and giving it a more real and
measurable meaning. The second is to track individuals
at risk for carotid narrowing and to put them on tighter
follow-up program. None of the tested people had a sig-
nificant carotid narrowing that required prompt referral
to a vascular surgeon. All those with carotid narrowing
>30% were invited for follow up test in 6 months. Small
doses of aspirin were recommended to all those with
high IMT or carotid narrowing >30% if they also had
either hypertension, diabetes mellitus or hypercholes-
terolemia. This approach was taken in spite of insuffi-
cient evidence for its absolute protective effect.
Increased level of CRP has been associated with symp-
tomatic cardiovascular disease [35] and dementia [22] or
stroke [4]. Recently, for the first time, a prospective study
demonstrated that treatment with statins can decrease
CRP level and the risk for myocardial infarct or death
from coronary causes [26] to support the need for CRP
assessment. Furthermore, a prospective study recently
has shown substantial improvement of survival in pa-
tients with severe peripheral artery disease treated with
statins [29]. Interestingly, only patients with elevated
high sensitive CRP benefited from the treatment with
statins.Due to lack of evidence for similar effect on stroke
or dementia we did not recommend specific treatment to
35% of our Brain Screen population with high CRP
level but referred them to their dentist with suspected
gingivitis and a recommendation for follow-up [23].
Brain Screen was developed to detect new and
modifiable risk factors by performing tests that are not
performed routinely by the Israeli health plans. As a re-
sult, we relied on the patients reports about the presence
of classical vascular risk factors like arterial hyperten-
sion, diabetes mellitus, atrial fibrillation etc. we based
our strategy on the quality of the basic medical care in
Israel, which is very aware of those risk factors. This is
also the reason why we chose not to perform an electro-
cardiogram.
Risk of falling
Only a relatively small percentage (16.4%) of the sub-
jects approached Brain Screen because of concerns
about their gait. However, we were able to identify an in-
creased risk of falls in 65% of the subjects who came to
Brain Screenfor other concerns and in 66% of the sub-
jects who did not report a history of falling. These sub-
jects benefited from a discussion about the danger of
falls and the importance of preventive behavior. They
also were told about the benefits of exercise and regular
walking for falls prevention [14] and were encouraged to
carry out these activities. We also advised the subjects
who had an increased risk of falls to assess their bone
density and, if needed, to obtain treatment for osteo-
porosis. Overall, Brain Screen provided critical infor-
mation to those with an increased risk of falls and
equipped them with guidelines that they could use to de-
crease their risk of falls and avoid common fall-related
sequelae, such as hip fractures, surgery, and nursing
home admission.
In addition to the above, Brain Screen was heavily
focused on detecting and treating depression and or-
thostatic hypotension as well as avoiding benzodi-
azepines which are of added value for the effort to de-
crease fall risk and severe injuries [12, 18].
Previous studies have called for an increased aware-
ness of the risk of falls, improving older adults knowl-
edge about falls and the ways to avoid them, and en-
couraging older adults to take preventative steps [12,
28]. To a large degree,Brain Screenis a response to this
call for action, educating a largely uninformed popula-
tion at increased risk of falls.
Delaying dementia
Memory disturbances might be the initial stage of de-
mentia but it is much more frequently a subjective feel-
ing associated with fear of Alzheimers disease. The goal
of any screening program should be to identify the indi-
viduals who are at risk to develop dementia, but no less
important is reassuring those who are functioning
within the normal range for their age. Because of the
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313
multi-factorial nature of cognitive decline, we believe
that only a program such as Brain Screen can provide
reliable data on the subjects status. All the participants
with vascular risk factors or gait disturbances were in-
formed that, in addition to their risk for strokes or falls,
these problems might be risk markers for future devel-
opment of cognitive decline. If we add obesity, which has
recently been shown to stand alone as a dementia risk
factor [13] similar to depression and anxiety [38, 40],
then most of the people who had been screened in the
Brain Screen program gained valuable new informa-
tion for behavioral modification that could affect their
risk for dementia. In other words, participation in
Brain Screen and exposure to the modern concepts
about the natural course of dementia and the signifi-
cance of risk factors to cognitive decline and onset of de-
mentia is by itself compelling justification for participa-
tion in the program.
The other objective of Brain Screen was to identify
people with MCI [24] and subjects who were normal
from among those who complained about memory dis-
turbances. In order to decrease the false positive diag-
nosis of MCI we required that the complaint of decline
in memory had to have lasted and progressed for at least
one year. Our streaked criteria for MCI might have
missed several people with amnestic MCI. A screening
program such as ours, however, should under-diagnose
and not over-diagnose MCI as long as there is no proven
protective treatment for Alzheimers disease. The avai-
lability of a detailed and structured neuropsychological
testing modality has given us an opportunity to look at
other cognitive domains, such as visuo-spatial perform-
ance, executive functions and attention. Because of the
lack of well-established criteria for non-amnestic MCI
and no subjective complaints about those domains by
the people who were tested, we neither diagnosed nor
discussed the importance of those cognitive domains as
risk factors for dementia.
People with cognitive decline and depression are al-
ways a challenge to diagnose due to the fact that depres-
sion could influence cognitive performance. We found a
higher percentage of depressed patients among those
who were diagnosed with MCI compared to those who
complained about memory loss but did not meet the cri-
teria for MCI.
Brain Screen gave us the opportunity to detect in-
dividuals who are on the course towards the develop-
ment of dementia. It also gave us the opportunity to re-
assure many worried people by ruling out their concern
that they were functioning abnormally for their age and
not in the early stages of dementia or Alzheimers dis-
ease.
All participants in the Brain Screen program re-
ceived general recommendations to watch their weight,
blood pressure and cholesterol level. We also recom-
mended and encouraged them to exercise daily for
3045 minutes, actively and purposefully challenge and
exercise their cognitive performances as well as main-
tain a healthy diet enriched by vitamins E and C.
People with amnestic MCI were invited to participate
in a computerized cognitive training program Cognifit
free of charge as well as to pay extra attention to the
control of vascular risk factors, depression and sleep dis-
turbances. Recent reports demonstrated that brisk walk-
ing and active participation in leisure time activities
could slow down or postpone dementia of Alzheimers
type [11] to support our recommendations.
Moreover, the coexistence of vascular atherosclerotic
changes in the Alzheimers brain with its role in the
pathogenesis of AD further supports the importance of
treating atherosclerotic risks factors. Furthermore,
statin treatment has been shown to delay the time of de-
mentia onset [41] to support the use of statins in non hy-
percholesterolemia people just to delay dementia [27] In
spite of the recent reports, we do not recommend statin
treatment for prevention of dementia and only the fu-
ture will give a clear answer to this possible therapeutic
approach.
In conclusion, based on the analysis of the first 514
consecutive people who were screened by Brain
Screen, we demonstrated that there is a place for such a
screening program. We were able to provide new and
valuable information to relatively educated individuals
who were very much aware of their health and aging and
were compliant to a concept of intervention based on a
risk factor profile for the delay or prevention of brain
disorders in the elderly.
We propose that the basic idea behind Brain Screen
should be adopted for the general population in the con-
viction that early detection and intervention for delay-
ing or preventing brain disorders, common among the
elderly population, is the only way to decrease the ever-
growing burden of those brain disorders on society.
Acknowledgment We thank Mrs. Orna Moor, RN MSc, and Liat Ra-
zon for all technical support, Mrs. Judith Knaani for superb secretar-
ial support, Mrs. Talia Herman MSc for technical support in gait as-
sessment, Prof. Shlomo Berliner and Dr. Einor Ben Assiag for support
in blood testing and data entry, Roni Zamishlani for data entry and
Prof. Amos D. Korczyn for guidance and support in the development
of the program.
307_315_Giladi_JON_1986 28.02.2006 13:56 Uhr Seite 313
314
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