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Calls to Action

The Healthy Brain Initiative Public Health Road Map Outlines 35 Action Items for State and Local Public Health and Their Partners

CDC developed a second in a series of road maps, The Healthy Brain Initiative: The Public Health Road Map for State and National Partnerships, 2013–2018. This document outlines how state and local public health agencies and their partners can promote cognitive functioning, address cognitive impairment for individuals living in the community, and help meet the needs of care partners. The road map provides actions that align with the core functions of public health under four domains: monitor and evaluate, educate and empower the nation, develop policy and mobilize partnerships, and assure a competent workforce. Public health agencies and private, nonprofit, and governmental partners at the national, state, and local levels are encouraged to work together on actions in the road map that best fit their missions, needs, interests, and capabilities. Learn more about CDC's Healthy Brain Initiative.

Promoting Detection and Diagnosis

Half of the people who meet the diagnostic criteria for dementia have not received a diagnosis from a physician.1-2 Early detection and diagnosis are essential to providing the best medical care and outcomes for people at any stage of the disease. Even without a way to cure or slow the progression of dementia, including Alzheimer’s disease, an early formal diagnosis offers the best opportunities for intervention and better outcomes. With a diagnosis in hand, individuals and their caregivers can access available treatments, build a care team, and better manage coexisting chronic conditions. Additionally, early diagnosis allows for some forms of cognitive impairment, such as those caused by drug interaction and dosage or a vitamin B12 deficiency, to be reversed. A meta-analysis of 39 published articles show that 9% of individuals experiencing dementia-like symptoms had potentially reversible forms of cognitive impairment with a proper workup.3

Considering Dementia in Preparedness Planning

Because dementia affects cognitive ability and judgment, those with cognitive impairment may be particularly vulnerable during all-hazard emergencies, yet their special needs may not be recognized during emergency planning and preparedness activities. Of the confirmed fatalities in Hurricane Katrina, it is unknown how many people had dementia, but disproportionate amounts were older than age 60. During Hurricane Sandy several older adults drowned alone in their homes. To help prevent future devastating situations like these, it is important to include experts in cognitive impairment, individuals with cognitive impairment and their care partners in local and state preparedness planning efforts, and to train responders and shelter staff about signs and symptoms of dementia, or conditions that can mimic cognitive impairment. Just as with the general population, it is important for individuals with dementia and their care partners to have a personal preparedness plan and to understand what resources [PDF 232K] are available so that they can deal with different kinds of disasters much more effectively when they occur. Learn more about emergency preparedness for older adults.


  1. Centers for Disease Control and Prevention. Self-Reported Increased Confusion or Memory Loss and Associated Functional Difficulties among Adults Aged ≥60 Years—21 States, 2011. MMWR. 2013;62(18):347-350.
  2. Boustani M, Peterson B, Hanson L, Harris R, Lohr K. Screening for dementia in primary care: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2003;138:927–937.
  3. Bradford A, Kunik ME, Schulz P, Williams SP, Singh H. Missed and delayed diagnosis of dementia in primary care: prevalence and contributing factors. Alzheimer Dis Assoc Disord. 2009;23(4):306-314. doi: 10.1097/WAD.0b013e3181a6bebc

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Monitoring Recent Physical Health

Older adults report many more physically unhealthy days than younger adults. Many of these unhealthy days are due to pain, discomfort, and impairments associated with common chronic diseases and conditions that increase with age, including arthritis, back and neck pain, diabetes, cardiovascular disease and cancer 1,2. Older adults who meet physical activity guidelines are less likely to experience frequent physical distress (14 or more physically unhealthy days) 3. Periodic monitoring of physically unhealthy days can identify whether older adults are experiencing declines in physical functioning to guide appropriate intervention. 

Evidence-based programs such as EnhanceFitness - an exercise program proven to increase strength, boost activity levels, and elevate mood 4 and Walk with Ease-a group walking program suitable for older adults with arthritis symptoms shown to improve health outcomes and boost confidence in symptom management and participation in physical activity 5 – are available for communities to implement. For more sedentary older adults, Active Living Everyday (ALED) is a group-based program developed to help sedentary people become and stay physically active. 6 Programs such as these may help older adults maintain or improve their physical health status.


  1. Centers for Disease Control and Prevention. Measuring Healthy Days. Atlanta, Georgia: CDC, November 2000. Table 2.
  2. Centers for Disease Control and Prevention. Health-related quality of life surveillance—United States, 1993–2002. In: Surveillance Summaries, October 28, 2005. MMWR. 2005:54(No. SS-4). Table 13.
  3. Brown DW, Balluz LS, Heath GW, Moriarty DH, Ford ES, Giles WH, Mokdad AH. Associations between recommended levels of physical activity and health-related quality of life—Findings from the 2001 Behavioral Risk Factor Surveillance System. Prev Med. 2003;37:520–528.
  4. Wallace JI, Buchner DM, Grothus L, Leveille S, Tyll L, LaCroix AZ, Wagner EH. Implementation and effectiveness of a community-based health promotion program for older adults. The Journals of Gerontology. 1998;53A:M301–M306.
  5. Callahan LF, Shreffler JH, Altpeter M, Schoster B, Hootman J, Houenou LO, Martin KR, Schwartz TA. Evaluation of group and self-directed formats of the Arthritis Foundation’s Walk With Ease Program. Arthritis Care & Research. 2001;63(8):1098–1107.
  6. Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl HW, Blair SN. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness, A Randomized Trial. JAMA. 1999;281(4):327–334.
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Addressing Mental Distress in Older Adults

While some aspects of mental health improve with age, many older adults still suffer with mental distress associated with limitations in daily activities, physical impairments, grief following loss of loved ones, care-giving or challenging living situations, or untreated mental illness such as depression or substance abuse. About 25% of adults aged 65 or older experience some type of mental health problem such as a mood disorder not associated with normal aging.1. While social ties are one of the strongest predictors of well-being, about 12% of adults aged 65 years or older report that they "rarely" or "never" received the social and emotional support they needed 2. Although mental health distress is undesirable by itself, it has been associated with unhealthy behaviors than can interfere with self-management and inhibit recovery from an illness. For example, older adults with frequent mental distress were less likely than those without frequent mental distress to be nonsmokers, to consume at least five fruits or vegetables daily, and to participate in moderate-to-vigorous physical activity during the average week.3 Health care providers and other service providers who have contact with older adults can help identify those with mental distress by periodically asking them whether they have experienced any stress, depression, or problems with their emotions. Health care providers can also help older adults recognize any unusual increase in stress or despondency and help them understand that these symptoms may not be simply a "normal part of aging."

On a population-level, self-reports of mental distress should be monitored as an indicator of the overall burden of mental health problems in older populations. Evidence-based programs are available to help improve mental health outcomes in older adults, such as IMPACT, a stepped, collaborative care program targeting older adults who have major depression or dysthymic disorder. IMPACT resulted in at least a 50% reduction in depressive symptoms, less functional impairment, and better quality of life in older adults.4 Another intervention, PEARLS, targets older adults with minor depression or dysthymia who are receiving social services from community agencies. PEARLS participants were three times more likely than those receiving usual care either to significantly reduce their depressive symptoms (43% vs 15%) or to completely eliminate their depression (36% vs 12%).(5) Participants also reported greater health-related quality of life improvements in functional and emotional well-being. Interventions such as these, as well as programs that increase social support such as those delivered by local Area Agencies on Aging may be effective in reducing symptoms of frequent mental distress in older adults.


  1. New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America. Final Report. Rockville, MD: New Freedom Commission on Mental health, 2003.
  2. Centers for Disease Control and Prevention and National Association of Chronic Disease Directors. The State of Mental Health and Aging in America Issue Brief 1: What Do the Data Tell Us? Atlanta, GA: National Association of Chronic Disease Directors; 2008.
  3. McGuire LC, Strine TW, Okoro CA, Ahluwalia IB, Ford ES. Modifiable characteristics of a healthy lifestyle in U.S. older adults with or without frequent mental distress: 2003 Behavioral Risk Factor Surveillance System. Am J Geriatr Psychiatry. 2007; 15:754–61.
  4. Unützer J, et al. Collaborative care management of late-life depression in the primary care setting. JAMA. 2002;288:2836–45.
  5. Ciechanowski O, Wagner E, Schmaling K, Schwartz S, Williams B, Diehr P, et al. Community-integrated home-based depression treatment in older adults: A randomized controlled trial. JAMA. 2004;291:1569–1577.
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Monitoring Vaccination Rates for Shingles

Shingles, also known as herpes zoster, is a disease that causes a painful skin rash and can lead to severe pain that can last for months or even years after the rash goes away, a condition known as post-herpetic neuralgia. Pain from shingles has been described as excruciating, aching, burning, stabbing, and shock-like, and can cause depression, anxiety, difficulty concentrating, loss of appetite, and weight loss. Shingles may interfere with activities of daily living like dressing, bathing, eating, cooking, shopping, and travel. To prevent shingles, CDC recommends a one-time dose of the shingles vaccine called Zostavax for use in people aged 60 years or older.1

To date, only national level data have been available to monitor the use of herpes zoster vaccination. According to data from the National Health Interview Survey, in 2010, 14.4% of adults aged 60 years or older reported receiving the vaccine, an increase from the 10.0% reported in 2009.2 Recognizing the need for state and selected MMSA (metropolitan and micropolitan statistical area) data, CDC created a question about shingles vaccination for the state-based Behavioral Risk Factor Surveillance System (BRFSS). Since 2009, this question has been available as an optional module to states to inquire about the receipt of shingles vaccination among adults aged 50 years or older; five states took advantage of this opportunity in 2009 and six states in 2010.3 Starting in 2014, the shingles vaccination question will be asked as part of the BRFSS "core" questionnaire every 3 years, which means all states will be collecting data on this recommended vaccine. These data will allow states and MMSAs to monitor trends in vaccination rates and identify disparities. This information will be useful for program planning and for identifying any problems so that corrective strategies can be adopted.


  1. Centers for Disease Control and Prevention. Protect Yourself Against Shingles: Get Vaccinated. Website. [PDF–98K]
  2. Centers for Disease Control and Prevention. Adult Vaccination Coverage–United States, 2010. MMWR, 2012;61(04);66–72.
  3. Centers for Disease Control and Prevention. BRFSS Questionnaires. Website. 2010
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