Balanced Brain acceptance therapy program shows promise for older veterans’ brain health

Up to 45 percent of dementia cases worldwide may be linked to modifiable health and lifestyle factors, from physical inactivity and social isolation to obesity, high cholesterol, diabetes, and alcohol use. Yet one of the most stubborn obstacles to protecting the aging brain may not be a molecule or a habit at all, but an emotion: the fear of decline itself. In a pilot study published in the Journal of Behavioral Medicine, researchers at the Veterans Health Administration and Stanford University describe the development and first test of a virtual group program, called Balanced Brain, that teaches older veterans to cope psychologically with the anxieties of cognitive aging while they adopt healthier lifestyles. Built on acceptance and commitment therapy, the program was delivered entirely over video telehealth to two small cohorts, and the overwhelming majority of participants — most of them in their eighties — stayed with it and rated it highly.

Older military veterans carry a heavier burden of dementia risk than the general aging population. Traumatic brain injury, posttraumatic stress disorder, exposure to harmful chemicals, and educational disparities are all more common among those who served, and each has been tied to poorer cognitive trajectories. Given the stakes, clinicians within the Veterans Health Administration make substantial efforts to promote brain health and preserve independence as veterans age, and the evidence base supports such efforts: combined exercise and cognitive training programs have improved learning, memory, and executive function in older veterans, while health coaching and structured multidomain interventions — pairing exercise groups, nutrition counseling, cognitive training, and scheduled social engagement — have outperformed passive, self-guided recommendations in older adults at elevated risk. But veterans still run into barriers when translating advice into action: uncertainty about where to start, minimal personal investment, a lack of social support, and, crucially, negative emotional reactions to cognitive change.

The dread itself may be neurotoxic in effect. Recent research indicates that fear of memory loss and of developing dementia is associated with withdrawal from social activities and other cognitively stimulating pursuits, which in turn damages cognition, mood, and quality of life. In other words, an unmanaged emotional response to brain health can erode brain health. Individuals confronting cognitive changes may feel sadness over lost abilities, anxiety about future declines, or anger at having to adjust, and those feelings can snowball into avoidance — skipping exercise, cancelling social plans, refusing to discuss cognitive concerns with a clinician. Each avoided activity strips away a protective factor. Earlier work showed that a self-guided intervention using mindfulness and behavioral activation skills to target fear of memory loss improved depression and anxiety and reduced self-reported memory lapses, suggesting that the emotional response to decline is a legitimate treatment target in its own right.

Balanced Brain builds on that insight using acceptance and commitment therapy, or ACT, a “third-wave” cognitive behavioral therapy that aims not to eliminate difficult thoughts and feelings but to increase psychological flexibility — the capacity to choose and persist in personally meaningful actions while adopting an open, nonjudgmental stance toward the difficult thoughts and emotions that arise along the way. The full ACT model spans six interlocking processes, including acceptance, cognitive defusion, present-moment awareness, a transcendent sense of self, values clarification, and committed action. For the intervention, the team distilled these into three pillars: “open,” the willingness to accept uncomfortable internal experiences such as fear of dementia; “aware,” conscious contact with the present moment and the ability to get unstuck from rigid, self-critical thought patterns; and “active,” initiating and sustaining behavior aligned with personal values. ACT has accumulating evidence for supporting health behavior change and chronic disease management, and meta-analyses show it reduces anxiety and depression specifically in older adults. In a recent trial in Spain, residents of six long-term care facilities with mild cognitive impairment who received group ACT combined with cognitive training improved in both cognitive function and quality of life compared with controls.

The designers also anchored the program in the Selective Optimization and Compensation model of successful aging, a framework developed by psychologists Paul and Margret Baltes. The model describes how people age well by selecting meaningful goals or tasks, optimizing performance on them by drawing on personal strengths and resources such as time, energy, and physical ability, and compensating for age-related losses with practical strategies or assistive devices. An older adult seeking more social connection might focus on a smaller number of relationships, schedule visits when energy is highest, and lean on phone or video chat to reach distant friends despite mobility limits. A 2024 cross-sectional study found that the components of psychological flexibility in ACT were associated with effective use of these strategies. In Balanced Brain’s theoretical model, an open, accepting stance toward age-related losses supports compensation; conscious awareness of the present moment allows thoughtful optimization of strengths; and ACT’s core principle of workability — judging a behavior by whether it serves one’s personally chosen values — guides the selection of goals in the first place.

To shape the program, the team first ran a needs assessment, interviewing six of 17 invited clinicians at two VHA medical centers: two neuropsychologists, a geropsychologist, a clinical psychologist, a geriatrician, and a primary care physician. Using a team-based rapid qualitative analysis across eight domains, the researchers coded the transcripts and stopped recruiting once new interviews ceased to yield new themes — the point of data saturation. The barriers clinicians described were often emotional. Veterans were frequently afraid of losing cognitive function, independence, or the ability to drive, and some avoided raising cognitive concerns with their doctors altogether. Ageism and stigma surfaced repeatedly; one geropsychologist recalled a veteran explaining, “I want to do more walks, but I don’t want to be seen using the walker.” Several clinicians noted that veterans were more willing to discuss brain health, and their emotional reactions to it, without family members present. Others described patients who seemed uninterested in the topic, lacked insight into their symptoms, or missed the link between habits like alcohol and cannabis use and long-term cognitive outcomes, alongside practical hurdles such as scarce social activities and physical limitations.

The interviews also produced a blueprint for what would work. Clinicians urged tailoring the intervention to each veteran’s values, taking time to understand what motivates each patient, and encouraging small, sustainable steps — gradually reducing alcohol consumption, for instance, rather than overwhelming patients with long handouts of recommendations. They endorsed specific techniques for emotional barriers, including mindfulness practice for those anxious about cognitive changes, collaboratively listing “what’s motivating them and what’s holding them back,” linking new activities to existing routines, and scheduling follow-ups with clear and specific goals. When shown the Balanced Brain concept, one neuropsychologist framed the therapeutic reframe precisely: rather than wanting to “change, fix, remove” cognitive symptoms, the aim is “embracing and optimizing.” Clinicians endorsed the group format for normalizing adjustment, providing accountability, and fostering camaraderie, and recommended adding substance use as a modifiable risk factor, explicitly addressing stigma and ageism, inviting caregivers to help with note-taking, and offering a booster session one month after the final class. They also flagged likely impediments: social comparison, extra obligations, telehealth technical challenges, and low adherence.

The resulting curriculum was organized into three modules — “healthy,” delivering psychoeducation on modifiable risk factors and a framework for personal brain health goals; “resilient,” teaching open and aware coping skills for difficult thoughts and feelings; and “engaged,” cementing self-directed pursuit of valued goals. Sessions ran weekly for 90 minutes on a secure, VHA-hosted video telehealth platform, with printed handouts and ACT worksheets mailed to participants in advance and each session ending with a behavioral commitment for the week ahead. The first cohort completed five weekly classes; after facilitator feedback, the second was expanded to six. Twenty-one veterans enrolled between March and June 2025 — 61 percent from an outpatient geriatrics clinic, 29 percent from telehealth exercise classes, and 10 percent from mental health clinics. Their average age was 80.4 years, 90 percent were men, and the group deliberately spanned cognitive statuses: 29 percent had a diagnosis of minor neurocognitive disorder, 5 percent age-related cognitive decline, and 5 percent mild dementia, while more than half carried a mental health diagnosis such as depression, PTSD, anxiety, or adjustment disorder.

Attendance provided the clearest signal of feasibility. Seventy-six percent of participants qualified as treatment completers, attending at least 75 percent of sessions — a benchmark drawn from similar telehealth ACT interventions — and 57 percent returned for the optional booster session one month later. On the Client Satisfaction Questionnaire-8, a validated eight-item measure with items such as “How would you rate the quality of service you received?” and “If a friend were in need of similar help, would you recommend our service to him or her?”, veterans reported high overall satisfaction on a 4-point scale. Notably, no compensation was offered, and veterans were assured their VHA care would be unaffected by their decision to participate — meaning those who showed up did so on their own motivation. The main practical snag was technological: telehealth connectivity issues were common, a reminder that even a well-attended virtual program for octogenarians is only as reliable as its bandwidth.

The findings carry the caveats of any pilot: no control group, a small sample from a single VHA system, and a designation as quality improvement rather than a formal trial by the Stanford University institutional review board. The researchers did not measure cognitive outcomes, so the study speaks to feasibility and acceptability, not efficacy. But the conceptual payoff is substantial. It suggests that dementia prevention efforts — which typically exhort people to exercise, eat well, and stay socially and cognitively engaged — may falter unless they also treat the fear, stigma, and ageism that stop people from starting. “The camaraderie and support of a group can be very therapeutic in and of itself,” one clinician told the team, which now envisions training other VHA clinicians to deliver the program and integrating it into mental health clinics as a preventative intervention. Another described the goal as helping veterans “feel a little more confident in addressing their brain health and not have this big black hole of what could happen.” With the global population aging and nearly half of dementia risk theoretically within reach of lifestyle change, the lesson of Balanced Brain is quietly radical: before the brain can be trained, the mind may need to be met.