HomeHealthNew dementia prevention method may be behavioral, not prescribed

New dementia prevention method may be behavioral, not prescribed


Cases of dementia are rising along with the aging of the world’s population, and another long-awaited Alzheimer’s drug, crenezumab, has proven ineffective in clinical trials, the latest of many disappointments. Public health experts and researchers argue that it is time to turn our attention to a different approach, focusing on eliminating a dozen known risk factors, such as untreated high blood pressure, hearing loss and smoking, rather than an exorbitant price. new drug whiz-bang.

“It would be great if we had drugs that work,” said Dr. Gill Livingston, a psychiatrist at University College London and chair of the Lancet Commission on Dementia Prevention, Intervention and Care. “But they are not the only way to go.”

Emphasizing modifiable risks, things we know how to change, represents “a drastic change in concept,” said Dr. Julio Rojas, a neurologist at the University of California, San Francisco. By focusing on behaviors and interventions that are already widely available and for which there is strong evidence, “we are changing the way we understand how dementia develops,” he said.

The last modifiable risk factor was identified in a study of visual impairment in the united states which was recently published in JAMA Neurology. Using data from the Health and Retirement StudyThe researchers estimated that about 62 percent of current dementia cases could have been prevented through risk factors and that 1.8 percent (about 100,000 cases) could have been prevented through healthy vision.

Although that’s a fairly small percentage, it represents a comparatively easy fix, said Dr. Joshua Ehrlich, an ophthalmologist and population health researcher at the University of Michigan and lead author of the study.

This is because eye exams, eyeglass prescriptions, and cataract surgery are relatively inexpensive and accessible interventions. “Globally, 80 to 90 percent of visual impairment and blindness are preventable through early detection and treatment, or have not yet been addressed,” said Dr. Ehrlich.

The influential Lancet Commission began leading the modifiable risk factor movement in 2017. A panel of clinicians, epidemiologists, and public health experts reviewed and analyzed hundreds of high-quality studies to identify nine risk factors that account for much of dementia in the world: high blood pressure, low educational levels, hearing problems, smoking, obesity, depression, physical inactivity, diabetes and low levels of social contact.

In 2020, the commission added three more: binge drinking, traumatic brain injury, and air pollution. The commission calculated that 40 percent of dementia cases worldwide could theoretically be prevented or delayed if those factors were removed.

“A massive change in the number of people with dementia could be achieved,” said Dr. Livingston. “Even small percentages, because so many people have dementia and it’s very expensive, can make a big difference to individuals and families, and to the economy.”

In fact, in richer countries, “it’s already happening as people get more education and smoke less,” he noted. Because the chances of dementia increase with age, as more people get older, the number of dementia cases continues to rise. But the proportions are falling in Europe and North America, where the the incidence of dementia has decreased by 13 percent per decade for the past 25 years.

Dr Ehrlich hopes the Lancet Commission will add visual impairment to its list of modifiable risks when it updates its report, and Dr Livingston said it would indeed be on the commission’s agenda.

Why would hearing and vision loss contribute to cognitive decline? “A neural system maintains its function through the stimulation of sensory organs,” explained Dr. Rojas, co-author of an accompanying article. editorial in JAMA Neurology. Without that stimulation, “there will be a death of neurons, a reorganization of the brain,” she said.

Hearing and vision loss may also affect cognition by limiting older adults’ participation in physical and social activity. “You can’t see the cards, so you stop playing with friends,” Dr. Ehrlich said, “or you stop reading.”

the link between dementia and hearing loss, the single most important factor that the Lancet Commission cited as modifiable risk, has been well established. There is less clinical data on the connection to vision decline, but Dr. Ehrlich is a co-investigator of a study in South India to see if providing glasses to older adults affects cognitive decline.

Of course, this approach to reducing dementia is “aspirational,” he acknowledged: “We’re not going to eliminate low education, obesity, all of that.”

Some efforts, such as raising education levels and treating high blood pressure, must begin in youth or middle age. Others require major policy changes; it is difficult for an individual to control air pollution, for example. Modifying habits and making lifestyle changes, such as quitting smoking, reducing alcohol consumption, and exercising regularly, is not easy.

Even fairly routine medical practices, such as measuring and monitoring high blood pressure and taking medication to control it, can be difficult for low-income patients.

Also, older Americans may realize that routine vision and hearing care are two services that traditional Medicare doesn’t cover.

It will pay for care related to diabetic retinopathy, glaucoma, or age-related macular degeneration, and covers cataract surgery. But for the most common problems that glasses can correct, “traditional Medicare won’t help you much,” said David Lipschutz, associate director of the nonprofit Center for Medicare Advocacy. It also won’t cover most hearing aids or exams, which are much higher expenses.

Medicare Advantage programs, provided through private insurers, typically include some vision and hearing benefits, “but look at the scope of coverage,” Lipschutz said. “They can apply $200 or $300 or $500 for hearing aids,” but at a typical price of $3,000 to $5,000 a pair, “they might still be out of your reach,” she said.

The expansion of traditional Medicare to include hearing, vision, and dental benefits was part of the Biden administration’s Build Back Better Act. But after the House passed it in November, Republicans and Democratic Sen. Joe Manchin III scuttled it in the Senate.

Still, despite the caveats and caveats, reducing modifiable risk factors for dementia could have huge benefits, and the Centers for Disease Control and Prevention has incorporated that approach into its National Plan to Address Alzheimer’s Disease.

A focus on these factors could also help reassure older Americans and their families. Some important risks of dementia are beyond our control: genetics and family history, and advancing age. Modifiable factors, however, are things we can act on.

“People are so afraid of developing dementia, losing their memory, their personality, their independence,” Dr. Livingston said. “The idea that you can do a lot about it is powerful.”

Even delaying its appearance can have a great effect. “If, instead of getting it at 80, you get it at 90, that’s a huge thing,” he said.

Vision and hearing exams, exercise, weight management, smoking cessation, blood pressure medication, diabetes care: “we are not talking about expensive interventions or sophisticated surgeries or consultations with specialists that are hours away” added Dr. Ehrlich. “These are things that people can do in the communities where they live.”



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