www.aging-us.com AGING 2023, Vol. 15, No. 4 Editorial Cognitive aging and dementia prevention: the time for psychology? David Bartrés-Faz, Cristina Solé-Padullés, Natalie L. Marchant Modifiable risk and protective factors (e.g. engaging in in major preventive clinical trials completed to date, active lifestyles and avoiding alcohol or smoking where several domains (e.g. reducing vascular risk amongst others) are seen as key agents for dementia factors by improving nutrition or physical exercise) prevention [1], and they also exert an important effect are targeted in parallel [7]. However, there is a lack of on cognitive trajectories of non-demented older adults understanding about how psychological factors, or [2]. Within this context, recent research has begun to indeed profiles, integrate with other lifestyle factors identify psychological processes that confer relative across different groups of individuals. This is risk and protection. For example, repetitive negative relevant, at least because: 1) engagement in thinking (RNT), a cognitive process defined by self- behaviours that may confer risk (e.g. sedentary relevant, persistent thoughts that elaborate on negative lifestyle, substance misuse) or protection (e.g. healthy themes, has been associated with greater burden of diet, cognitively stimulating activities) may strongly typical Alzheimer’s disease (AD) pathological brain modulate the impact of psychological factors on markers and accelerated cognitive decline over time cognitive function, and 2) psychological factors may [3]. In contrast, self-reflection [4], as well as purpose act as potent drivers of engagement in other healthy in life and other components of psychological well- lifestyles. For example, related to the use of being, may help to maintain cognition and boost maladaptive stress coping strategies, individuals with cognitive resilience against neuropathological burden high and persistent levels of rumination and worry [5]. The possibility of incorporating psychological might be more prone to social isolation and elements as key players in affecting one of the most loneliness, which by themselves represent risk factors important public health issues of the century opens a for dementia in advanced age. In this case, preventing window of great therapeutic opportunity, particularly social disconnection would be important, but because fundamental psychological processes are at additionally improving stress coping styles could be the core of cognitive-behavioural interventions that paramount. On the other hand, in the context of may help reduce dementia risk [6]. However, for this individuals with low engagement in protective emergent area to develop and wield maximum benefit, lifestyles, the consideration of life purposes and major unanswered questions need to be addressed. meaningful values for the individual could lead to the Here, we highlight three main areas for future identification and recommendation of new and research. alternative healthy behaviours, which the individual First, to date the effects of potential psychological risk could potentially adhere to with high motivation. and protective factors have been mainly reported in Developing further and systematic knowledge in this isolation. While helpful to identify key components, this area, by using for instance health mobile technologies approach cannot account for the complexity of to monitor behaviour as a function of psychological psychological processes that may exist within a person, profiles, could help in designing personalised, and and how potentially competing processes may interact ideally more effective, future interventions for habit to impact on cognitive status, presence of biomarkers or change. brain integrity measures. To address this issue, we Finally, there is a need to explore brain mechanisms recently used a person-centered approach to define through which psychological processes may exert their psychological profiles of participants. We found that protective or deleterious effects. While dysregulation of individual psychological risk and protective factors biological pathways associated with stress response (i.e. aggregated into three identifiable psychological profiles hypothalamic–pituitary–adrenal (HPA) axis) are which were consistent in two independent European frequently evoked in literature, our knowledge of cohorts (Figure 1). Future studies are needed to systems-level brain network expression is only determine the nature of these different psychological beginning to emerge. In this regard, and using resting- profiles as being protective or risk factors. Such state functional magnetic resonance imaging (fMRI), a knowledge would contribute to more individualized recent study from our group [8], investigated the psychological preventive therapeutic strategies. associations between ratings of RNT and the functional Second, the current approach to consider risk and connectivity of three main circuits; namely, the so- protective factors across multiple domains is reflected called triple network of attention. Overall, the default www.aging-us.com 889 AGING mode network from individuals with high RNT was that the findings were observed amongst middle-aged less connected with the executive control network and healthy individuals, hence reflecting that associations more connected with the anterior salience network. between psychological processes and the status of Although speculative, these findings may indicate that brain networks can already be detected well before top-down executive control systems are compromised age-related accelerated cognitive changes or early amongst individuals with high RNT, perhaps under- manifestations of dementia may occur. However, lying the previously reported cognitive decline many questions remain for future research. For associated with RNT [3], whereas on the other hand, example, is there a specificity of psychological risk connectivity between networks engaged in emotional and protective factors regarding their association with processing (i.e. the anterior salience network) and brain integrity metrics, compared to those related to introspective thought (i.e. default mode network) are clinical manifestations such as anxiety and depression accentuated. Another interesting aspect of this study is symptoms? Recent literature suggests so, and for Figure 1. Results from a latent profile analysis (LPA) in two independent European cohorts: the middle-aged Barcelona Brain Health Initiative (BBHI, N=741, mean age 53) and the older-adult Medit-Ageing (N=279, mean age 71) studies. The figure shows strikingly similar latent profiles in both cohorts, each identifying a three-class solution: “high levels of psychological risk factors” (Class- 1), “average levels of psychological risk and protective factors” (Class-2) and “low levels of psychological protective factors” (Class-3). www.aging-us.com 890 AGING instance, the association between self-reflection and 6. Stott J, et al. Lancet Healthy Longev. 2023; 4:e12–22. increased glucose metabolism in temporoparietal https://doi.org/10.1016/S2666-7568(22)00242-2 regions was observed even after adjusting for PMID:36509102 demographic variables, APOE status as well as 7. Röhr S, et al. Curr Opin Psychiatry. 2022; 35:285–92. depression [4]. Future research should also shed light in https://doi.org/10.1097/YCO.0000000000000792 other key topics, such as whether psychological PMID:35703256 profiling may be useful to define populations most likely to benefit from preventive interventions, or if 8. Solé-Padullés C, et al. Front Aging Neurosci. 2022; complementing the standard assessment of psycho- 14:1062887. logical processes (e.g. questionnaires) using a more https://doi.org/10.3389/fnagi.2022.1062887 fine-grained approach, for example with real-time PMID:36589537 evaluations during experimental studies, would improve our sensitivity to detect associations with cognition and David Bartrés-Faz: Department of Medicine, Faculty dementia biomarkers. of Medicine and Health Sciences and Institute of In summary, we propose that with momentum gathering, Neurosciences, University of Barcelona, Barcelona, Spain now is the time for psychology to make important contributions to cognitive ageing and dementia Correspondence: David Bartrés-Faz prevention research. More refined characterization of Email: dbartres@ub.edu psychological processes that may confer relative risk or Keywords: cognitive aging, psychological factors, protection, improved understanding of their interplay dementia, prevention with other modifiable factors and of their biological Funding: D.B-F was supported by an ICREA Academia 2019 substrates, and their consideration and incorporation into award from the Catalan Government. C-SP and D.B-F were future clinical trials are all critical avenues to pursue. supported by a Spanish Ministry of Science, Innovation Progress in this area should lead to the creation and and Universities (MICIU/FEDER; grant number RTI2018- implementation of a psychological framework, with 095181-B-C21) and a Fundació la Marató de TV3 (ref. operational definitions, that would allow researchers and 589/C/2021) grants. NLM was supported by the clinicians to work together to promote healthy cognitive Alzheimer's Society (AS-SF-15b-002). ageing and dementia prevention. Copyright: © 2023 Bartrés-Faz et al. This is an open access article distributed under the terms of the Creative Commons REFERENCES Attribution License (CC BY 3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided 1. Livingston G, et al. Lancet. 2020; 396:413–46. the original author and source are credited https://doi.org/10.1016/S0140-6736(20)30367-6 PMID:32738937 Received: February 17, 2023 Published: February 27, 2023 2. Jia J, et al. BMJ. 2023; 380:e072691. https://doi.org/10.1136/bmj-2022-072691 PMID:36696990 3. Marchant NL, et al. Alzheimers Dement. 2020; 16:1054–64. https://doi.org/10.1002/alz.12116 PMID:32508019 4. Demnitz-King H, et al. Neurology. 2022; 99:e1422–31. https://doi.org/10.1212/WNL.0000000000200951 PMID:35853750 5. Willroth EC, et al. 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