To view or not to view: television and mental health.

Fogel and Carlson (1) report in this issue of the Southern Medical Journal that talk shows or soap operas as a favorite television category were associated with poorer scores on various cognitive measures in a cross-sectional analysis of 289 older women. While several observational studies have reported on the association between increased participation in cognitively stimulating activities and reduced risk of dementia in older adults, (2,3) this study examines the flip side of the coin. Is participation in noncognitively stimulating activities associated with increased risk of cognitive decline?

The mechanisms by which leisure activities may reduce (or increase) cognitive decline include its effects on cognitive reserve, chronic stress, and encouraging a healthier lifestyle. (3) The cognitive reserve hypothesis postulates that cognitive activities give rise to neural changes that build a buffer against the dementing process in the brain. (4) Exposure to enriched environments is associated with neurogenesis in animal models. (5) Enhanced social networks have been reported to reduce risk of dementia, perhaps by reducing stress. (3) Television viewing may be a proxy for health behaviors, such as a sedentary lifestyle, which increases risk for cardiovascular disease and cognitive impairment.

The cognitive risks associated with television viewing may depend on the timing and duration of exposure as well as the degree of interaction. (1) Television viewing unlike many other putative risk factors for dementia has only been around for few decades, with many older adults having had their initial exposure in midlife. Increased television viewing in midlife has been reported to be associated with increased risk of Alzheimer's disease in later life. (6) With televisions becoming a ubiquitous fixture in American households, the age of exposure will shift downwards. Reasons for increased television viewing among the elderly include physical frailty, depression, and social isolation. A public health challenge will be to provide home-based, cognitively-stimulating activities, which are safe and enjoyable.

So should we pack up our television guides and throw out the remote controls? Not yet! The cross-sectional design of this study does not allow us to draw causal inferences. Subjects destined to develop dementia might show a downward drift in their viewing preferences, from PBS to soaps, accounting for the reported association. (1) The results could also be specific to older women as gender differences exist in viewing habits. Depending on the program, television viewing might even have cognitive benefits. Generations of children have grown up learning their alphabets, and presumably increasing their cognitive reserve, (4) from programs such as Sesame Street. Television viewing may also help reduce chronic stress levels.

As the authors suggest, asking patients about participation in leisure activities including television viewing may be very useful to gauge cognitive status in clinical practice, especially comparing changes or decline in levels of participation. Mounting evidence from observational studies suggests that it is time to examine the role of leisure activities in the context of clinical trials to formulate evidence-based policy recommendations. (2,3) Although prevention of dementia has emerged as a major public health priority, there is a paucity of preventive strategies. (4) Most drugs currently available for dementia treatment have modest effects at best, and do not substantially impact disease progression. (7) Hence, all forms of primary and secondary prevention need to be explored more fully. In the meantime, choose your leisure activities (and television programs) wisely.

References

1. Fogel J, Carlson MC. Soap operas and talk shows on television are associated with poorer cognition in older women. South Med J 2006;99 226-233.

2. Verghese J, Lipton RB, Katz MJ, et al. Leisure activities and the risk of dementia in the elderly. N Engl J Med 2003;348:2508-2516.

3. Fratiglioni L, Paillard-Borg S, Winblad B. An active and socially integrated lifestyle in late life might protect against dementia. Lancet Neurol 2004;3:343-353.

4. Katzman R. A neurologist's view of Alzheimer's disease and dementia. Int Psychogeriatr 2004;16:259-273.

5. Churchill JD, Galvez R, Colcombe S, et al. Exercise, experience and the aging brain. Neurobiol Aging 2002;23:941-955.

6. Lindstrom HA, Fritsch T, Petot G, et al. The relationships between television viewing in midlife and the development of Alzheimer's disease in a case-control study. Brain Cogn 2005;58:157-165.

7. Petersen RC, Thomas RG, Grundman M, et al. Vitamin E and donepezil for the treatment of mild cognitive impairment. N Engl J Med 2005;352:2379-2388.

Joe Verghese, MD

From the Department of Neurology, Albert Einstein College of Medicine. Bronx, NY.

Reprint requests to Joe Verghese, MD, Einstein Aging Study, Albert Einstein College of Medicine, 1165 Morris Park Avenue, Bronx, New York 10461. Email: [e-mail]

Accepted December 21, 2005.