Cases of dementia are rising as the world’s population ages, and another highly anticipated Alzheimer’s drug, crenezumab, has been shown to be ineffective in clinical trials – the latest of many disappointments. Public health experts and researchers say it’s high time to turn our attention to a different approach – focusing on eliminating a dozen already known risk factors, like untreated high blood pressure. , hearing loss and smoking, rather than an exorbitantly priced, super new drug.
“It would be great if we had drugs that worked,” said Dr Gill Livingston, a psychiatrist at University College London and chair of the Lancet Commission on Dementia Prevention, Intervention and Care. “But they’re not the only way forward.”
Focusing on modifiable risks — things we know how to change — represents “a radical shift 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 published recently in JAMA Neurology. Using data from the Health and Retirement Study, the researchers estimated that about 62% of current cases of dementia could have been prevented according to risk factors and that 1.8%, or about 100,000 cases , could have been avoided with healthy vision.
While that’s a fairly small percentage, it represents a relatively easy fix, said Dr. Joshua Ehrlich, an ophthalmologist and population health researcher at the University of Michigan and lead author of the study.
Indeed, eye exams, eyeglass prescriptions and cataract surgery are relatively inexpensive and accessible procedures. “Globally, 80-90% of visual impairment and blindness are preventable with early detection and treatment, or have not yet been treated,” Dr. Ehrlich said.
The influential Lancet Commission began leading the modifiable risk factor movement in 2017. A panel of physicians, epidemiologists, and public health experts reviewed and analyzed hundreds of high-quality studies to identify nine risk factors. risk factors responsible for much of dementia worldwide: high blood pressure, low levels of education, hearing impairment, smoking, obesity, depression, physical inactivity, diabetes and low levels of social contact.
In 2020, the commission added three more: excessive alcohol consumption, traumatic brain injury and air pollution. The commission calculated that 40% of dementia cases worldwide could theoretically be prevented or delayed if these factors were eliminated.
“A massive change could be made in the number of people with dementia,” Dr Livingston said. “Even small percentages – because so many people have dementia and it’s so expensive – can make a huge difference to individuals and families, and to the economy.”
In fact, in richer countries, “this is already happening because people are more educated and smoke less,” she pointed out. Since the risk of dementia increases with age, as more and more people reach old age, the number of cases of dementia continues to rise. But the proportions are falling in Europe and North America, where the incidence of dementia has fallen by 13% per decade over the past 25 years.
Dr Ehrlich hopes the Lancet Commission will add visual impairment to its list of modifiable risks when updating its report, and Dr Livingston said it will indeed be on the commission’s agenda.
Why would hearing and visual loss contribute to cognitive decline? “A neural system maintains its function through stimulation of sensory organs,” explained Dr. Rojas, co-author of an accompanying editorial in JAMA Neurology. Without this stimulation, “there will be a disappearance of neurons, a rearrangement of the brain,” he said.
Hearing and vision loss may also affect cognition by limiting older people’s 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 the Lancet Commission cited as a modifiable risk, has been well established. There is less clinical data on the link with impaired vision, but Dr Ehrlich is co-investigator of a study in southern India to determine whether providing glasses to the elderly affects decline cognitive.
Of course, this approach to reducing dementia is “ambitious,” he acknowledged: “We’re not going to eliminate low education, obesity, all of that.
Some efforts, such as raising education and treating high blood pressure, should begin in youth or midlife. Others require major policy changes; it is difficult for an individual to control air pollution, for example. Changing habits and making lifestyle changes — like quitting smoking, cutting down on alcohol, and exercising regularly — isn’t easy.
Even fairly common medical practices, such as measuring and monitoring high blood pressure and taking medication to control it, can be difficult for low-income patients.
Additionally, older Americans will likely notice that routine vision and hearing care are two services that traditional health insurance does not cover.
It will pay for care related to diabetic retinopathy, glaucoma or age-related macular degeneration, and it will cover cataract surgery. But for more common problems correctable with glasses, “traditional health insurance 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 by private insurers, typically include some vision and hearing benefits, “but look at the extent of coverage,” Lipschutz warned. “They might charge $200, $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 reach,” he said .
Expanding traditional health insurance 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 Sen. Joe Manchin III, a Democrat, scuttled it in the Senate.
Yet 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 this approach into its national plan to combat dementia. Alzheimer’s disease.
Focusing on these factors could also help reassure older Americans and their families. Some significant dementia risks are beyond our control – genetics and family history, and age itself. Modifiable factors, however, are things we can influence.
“People are so afraid of developing dementia, losing memory, personality, independence,” Dr Livingston said. “The idea that you can do a lot about it is powerful.”
Even delaying its onset can have a big effect. “If instead of getting it at 80 you get it at 90, that’s a huge thing,” she said.
Eye and hearing exams, exercise, weight control, quitting smoking, blood pressure medication, diabetes care – “we’re not talking about expensive procedures or fancy surgery or seeing specialists at hours of driving,” added Dr. Ehrlich. “These are things that people can do in the communities where they live.”
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