There are differing views on the value of cognitive screening of older adults in a primary care setting. Many providers point to the lack of disease-modifying treatments for Alzheimer’s Dementia and related dementias (ADRD) as a reason to not universally screen older adults for cognitive deficits. If I don’t have anything to give my patients to get better, what’s the point in revealing they might be at risk of dementia, or that they have early disease? Is dementia a ‘normal’ or ‘expected’ part of reaching older age? The answers to these questions are complex, but importantly, much more hopeful than we may realize. It is true that age is the strongest risk factor for an Alzheimer’s Disease (AD) diagnosis, the most common form of dementia; 10% of people in their 60s will be diagnosed with AD, but upon reaching their 80s, as much as 40% are diagnosed with AD (leading to approximately half a million cases every year). After age, genetics and family history play a large role in determining our dementia risk. But after that, who we are and how we lead our lives have the greatest impact on our likelihood of developing dementia. Thus, it is a misconception that without disease-modifying treatments, there is not much we can do to fight this terrible disease that robs us of our most valuable possession: our own identities.
Current scientific evidence demonstrates that there are in fact many things we can do to ward off dementia. A study led by a panel of international experts, commissioned by the Lancet, uncovered 12 potentially modifiable risk factors that are responsible for up to 40% of dementia cases worldwide. Perhaps surprisingly, these are related to seemingly simple changes, many of which are already on our ‘radar’ like being more physically active; controlling our weight, blood sugar, and blood pressure; getting treatment for depression; nurturing meaningful social connections; addressing hearing loss; and stopping smoking. If we all took these actions today, we would slash over a third of dementia cases next year. This means that just by taking better care of our own health we could spare 175,000 people in the next year from the pain and suffering that follows an AD diagnosis.
While these numbers are powerful, the most important statistics to us concern our loved ones, and our families. How much can we change about our and their future? Turns out that taking care of our health and lifestyle is the single most important thing we can do to prevent an encounter with dementia down the road, and the time necessary to reap the benefits may surprise you. In 2015, researchers in Finland conducted a now groundbreaking clinical trial, called the FINGER study, with more than 2,500 older adults and demonstrated that engaging in an intensive multi-domain lifestyle intervention (one that included physical exercise, nutritional counseling, brain training and management of vascular risk factors) for two years reduced dementia risk (or prevented dementia) by as much as 30% when compared to good old-fashioned health advice. This decrease in dementia risk is more powerful than any other therapeutic currently approved.
And even in the presence of cognitive deficits, pursuing such healthy behaviors can reduce the severity of disability. Maintaining healthy behaviors can help, among other things, to ward off frailty, a condition affecting about 40 in every 1000 older adults. Frailty presents as a vulnerability and decline in function across multiple organs. Frail adults struggle with weakness and exhaustion and have a harder time fighting back against common stressors, ranging from a cold to a sprained ankle. Being frail predisposes us to poorer health outcomes and falls, and importantly, robs us of our memory significantly faster. A recent study reported that older adults with cognitive impairment and frailty develop dementia two times faster than those who are not frail. The good news is that following brain-healthy habits like those already discussed, like being more physically active and getting better nutrition, can combat some of the hallmark signs of frailty (weakness, slowness, exhaustion, weight loss, and low physical activity).
But how can we practically prioritize our health and lifestyle in the hectic lives we lead today, and encourage patients to do the same? While lifestyle interventions are powerful and broadly accessible to most people, they also require sustained effort and dedication. Take exercise for example – there is ample evidence on the brain health benefits of walking, a cost-effective and safe option for most, yet many people remain sedentary. Another important lesson from the FINGER study that likely contributed to its success was that the intervention was personalized to the individual. Participant adherence to the 2-year intervention was very high (above 85%), and a broader implication of these findings is that we need to develop frameworks to systematically increase access to these multi-domain personalized lifestyle interventions.
A promising option in this scenario is to empower primary care providers (PCPs) more, given that they are the first point of contact for many individuals in health systems, and they remain in continuous contact with those who have multiple morbidities. In a time of considerable burnout of the healthcare force, the last thing we need is additional responsibilities for our PCPs. But an important consideration is that PCPs know their patients and are well-positioned to support behavior change in the most effective way and at the earliest point. For example, a systematic review of 48 randomized controlled trials concluded that self-management support interventions in primary care effectively improved various health outcomes for a wide range of lifestyle-related chronic diseases, when compared to usual standard of care. Importantly, the authors identified the ‘active ingredients’ that drove the positive outcomes: knowledge enhancement, independent monitoring of symptoms, a personalized action plan, coping/stress management, monitoring of progress, tailored feedback, and enhanced problem-solving/decision-making. This highlights a unique opportunity to translate learned lessons from other chronic conditions (like hypertension, diabetes and obesity) to the care of ADRDs, which as aforementioned, are also lifestyle-related chronic diseases, although we do not routinely think of them as such.
Encouragingly, a recent Global Brain Health Survey shows an appetite among individuals to care for their brain health with better lifestyle-related habits. A total of 70% of respondents indicated that memory problems would be a key motivator for them to improve their lifestyle on two conditions: 1) that the changes would be effective and 2) that this advice came from their care team, further strengthening the argument made above. Thus, while the general notion of the importance of healthier lifestyles might not be enough to spur meaningful behavior change, individuals appear more likely to pursue changes if they have a greater awareness of the direct link to their brain health. Critical to this argument is that people’s motivation was directly tied to their awareness of their own brain health, and this requires routine brain health evaluations. More proactive screening of cognitive performance empowers individuals and their care teams and enables a faster translation of great science into better actions and healthier lives.
A truly transformative impact on a given individual’s dementia risk will require a societal and public health transformation that emphasizes brain health promotion throughout the lifespan and breaks from the somewhat simplistic disease model. Ultimately, the focus has to be on helping individuals, not on treating diseases. An important part of this is to empower PCPs in their work to help their patients help themselves with proactive steps to protect brain health. At the same time, support will be needed through public health policies and incentives to ensure adoption and adherence that include personalized coaching, and a strong social support network.
On an individual level, we must realize that we – and our loved ones – do not need to do a laundry list of things to protect our brain health, but rather recognize the transformative power that is committing to a healthier life. Furthermore, being an ‘influencer’ is not just something limited to social media platforms; there is scientific evidence that healthy behaviors are infectious, and have the capacity to spread through our communities. In essence, for meaningful change to happen, we need to be both individual and collective brain health ambassadors.
About Joyce Gomes-Osman,
Joyce Gomes-Osman, PT, Ph.D. is Vice President of Interventional Therapy at Linus Health and a Voluntary Assistant Professor of Neurology at the University of Miami Miller School of Medicine.
About Alvaro Pascual-Leone
Alvaro Pascual-Leone, MD, Ph.D. is the Chief Medical Officer of Linus Health, a Professor of Neurology at Harvard Medical School, a Senior Scientist at the Hinda and Arthur Marcus Institute for Aging Research, and the Medical Director of the Deanna and Sidney Wolk Center for Memory Health at Hebrew SeniorLife.