In a report presented at the Alzheimer’s Association International Conference (AAIC; London, UK, 16–20 July 2017), The Lancet International Commission on Dementia Prevention, Intervention and Care has reported that more than one-third of global dementia cases may be preventable through addressing lifestyle factors that impact an individual’s risk.
The Commission brings together 24 experts from across the globe to consolidate recent advances in our understanding of dementia risk factors, treatment and care, and offer advice on disease prevention and management. To produce the report, the Commission conducted a review and meta-analysis: these formed the basis upon which they then extended current models of risk, including hearing loss and social isolation.
Out of this, the international team proposed a new life-course model of risk, highlighting opportunities for prevention. The key recommendations are outlined below:
- Be ambitious about prevention. Interventions for established risk factors may have the potential to delay or prevent one third of dementias.
- Treat cognitive symptoms. To maximize cognition, people with Alzheimer’s dementia or dementia with Lewy bodies should be offered cholinesterase inhibitors at all stages, or memantine for severe dementia.
- Individualize dementia care. Good dementia care spans medical, social and supportive care; and should be tailored to unique individual and cultural needs, preferences, and priorities.
- Care for family carers. Family carers are at high risk of depression. Effective interventions reduce the risk and treat the symptoms, and should be made available.
- Plan for the future. People with dementia and their families value discussions about the future and important upcoming decisions.
- Manage neuropsychiatric symptoms. Management of the neuropsychiatric symptoms of dementia – including agitation, low mood or psychosis – is usually psychological, social, and environmental, with drug treatment reserved for more severe symptoms.
- Consider end of life. A third of older people die with dementia, so it is essential that professionals working in end-of-life care consider whether a patient has dementia as they may be unable to make decisions about their care or express their needs and wishes.
The team also estimated the contribution of key risk factors to overall dementia incidence at the population level: combined, these data suggest that approximately 35% of all dementia cases are attributable to nine potentially modifiable risk factors across the lifespan. These include: education in early life; hypertension, obesity and hearing loss in mid-life; and depression, diabetes, physical inactivity, smoking and low social contact in later life.
The report’s authors estimate that 8% of all dementia cases could be associated with poor early school education, and 5% could be associated with smoking.
As a result of these findings, the Commission issued recommendations for targeted public health strategies to lower the global burden of dementia. These include:
- The authors strongly recommend vigorously treating hypertension in middle-aged and older people without dementia to reduce dementia incidence.
- Other recommended interventions include more childhood education, getting regular exercise, maintaining social engagement, stopping smoking, and management of hearing loss, depression, diabetes and obesity.
“While public health interventions will not prevent, or cure all potentially modifiable dementia, intervention for cardiovascular risk factors, mental health, and hearing may push back the onset of many people for years,” said Gill Livingston (University College London, UK) and lead author of The Lancet Commission. “Even if some of this promise is realized, it could make a huge difference and we have already seen in some populations that dementia is being delayed for years. Dementia prevalence could be halved if its onset were delayed by 5 years.”
Co-author Lon Schneider (University of Southern California, CA, USA) added: “Overall, there is good potential for prevention and, once someone develops dementia, for care to be high-quality, accessible, and give value to an underserved, growing population. Effective dementia prevention and care could transform the future for society and vastly improve living and dying for individuals with dementia and their families. Acting now on what we already know can make this difference happen.”