Societies must not wait to address the risk factors for dementia, according to a new Lancet commission on dementia prevention, intervention and care released in late July.
According to the commission, which involved Dalhousie University’s Dr. Kenneth Rockwood and 32 other leading dementia experts, concerted efforts to reduce risk could prevent as many as a third of all dementias — and the worldwide prevalence of dementia would be cut in half if the onset of the disease could be delayed by just five years across the board.
About 47 million people were living with dementia in 2015. This number is projected to rise to more than 140 million by 2050, if current trends continue.
“Big changes in thinking are needed,” says Dr. Rockwood, who is the Kathryn Allen Weldon Professor of Alzheimer Research, a professor in the departments of Medicine (Division of Geriatric Medicine) and Community Health & Epidemiology, and the only Canadian involved in the Lancet commission. “We need to be ambitious about prevention and we need widespread reform in how we deliver our systems of care — fundamental transformation, not just adaptation.”
Dementia prevention starts early in life
In its analysis of the global evidence surrounding the prevention and delay of dementia, the Lancet commission discovered that education — starting in early childhood — is the most important protective factor.
Close behind are preventing and managing hearing loss, strengthening social connections, staying physically active, maintaining a healthy weight, and not smoking. It’s also important to manage chronic problems like depression, diabetes and blood pressure.
“By the time someone is in their sixties or seventies, they may have missed many of the potential pathways to prevention,” says Dr. Rockwood. “For Maritimers, the crucial message is to quit smoking, manage mid-life obesity and keep blood pressure under control.”
Dr. Rockwood’s research on identifying, assessing, managing and preventing frailty — with Dalhousie mathematician, Dr. Arnold Mitniski — underpinned many aspects of the Lancet commission’s analysis.
“Our work on frailty has highlighted the vital role of physical health and fitness in preventing and delaying dementia,” he says. “The impact of regular vigourous physical activity on brain health cannot be overstated.”
A public health issue
Countries need to develop comprehensive strategies for minimizing risk, diagnosing early and delivering effective care.
“We lack a national dementia strategy in Canad — there is huge variation from province-to-province. It’s difficult to make headway in the absence of a cohesive national response,” Dr. Rockwood says. “The U.K., in contrast, has made dementia a public health issue, rather than an individual or family health care issue. By analyzing physician practice patterns district by district, they’ve dramatically increased the diagnosis rate and shed a bright light on the inadequacy of services, paving the way to change.”
The rising tide of dementia demands innovative new approaches to providing not only day-to-day care to affected individuals, but acute health care services to everyone.
“Health-care professionals in general do not understand how best to estimate the risk of drugs and surgeries for frail older people,” Dr. Rockwood explains. “What you can get away with in a 30-year-old — in terms of surgery, for example — can precipitate a serious drop in cognitive function in a 75-year-old. The solution is not to deny treatment to the older person — it’s to make health care less hazardous for everyone. Instead of thinking about this as a nuisance, we need to embrace it as an opportunity.”
Models of dementia care must also evolve to replace or augment the nursing home concept — seniors’ villages and small-group homes, for example — with better supports for family members who are providing dementia care at home.
“We face a great challenge ahead, for individuals, families and society as a whole,” Dr. Rockwood notes. “The Lancet commission took a broad look at this, with specific recommendations about how to address the challenge more proactively, across the lifespan. The necessary changes would have a significant impact on public policy around the world—working in a multinational group like the commission leads to the sharing of information and ideas and lends urgency to the issue.”
Ten key messages from the Lancet commission on dementia prevention, intervention and care:
1. The number of people with dementia is increasing globally
2. Be ambitious about prevention
3. Treat cognitive symptoms
4. Individualize dementia care
5. Care for family carers
6. Plan for the future
7. Protect people with dementia
8. Manage neuropsychiatric symptoms
9. Consider end of life
10. Innovate to improve prevention, treatment and care
Access the full report at the Lancet website.