Dementia or brain damage and injury as a mental health and neurology medical symbol with a thinking human organ made of crumpled paper torn in pieces as a creative concept for alzheimer disease.

Dementia or brain damage and injury as a medical symbol for mental health and neurology with a thinking human organ made of crumpled paper torn into pieces as a creative concept for Alzheimer's disease.

In the past decade, important strides have been made in the fight against dementia. A critical victory in this context is debunking the idea that cognitive decline and dementia are a natural part of aging. Current evidence actually suggests that an individual’s lifestyle may be more important than we realize in determining dementia risk, and this comes with significant clinical implications for how we treat older people.

Key among this growing body of evidence is a now a groundbreaking prospective interventional study by Finnish scientists which found that a two-year brain health program aimed at improving lifestyle was effective in reducing the risk of dementia by 30% compared to good old-fashioned health advice. Study participants were individuals in their 60s and 70s who had comorbidities identified as risk factors for dementia and also had mild cognitive deficits. They also saw a 25% improvement in their overall mental acuity (their memory was 40% better, their brains were 150% faster at performing mental tasks and their problem-solving ability also increased by 80% ). While 30% may not seem like a big reduction in dementia risk, it’s worth noting that it’s better than any currently approved dementia drug. A crucial part here is that this is the first prospective randomized controlled trial of its kind, thereby establishing a causal relationship between participation in a program targeting multiple healthy brain behaviors, and reducing the risk of dementia and improving mental acuity.

While these results are certainly exciting, so what most surprising for this study, as with others like him, was that the activities and schedule of the program were perhaps quite doable making their potential role in improving brain health even more promising. Participants exercised for one hour three to seven days a week. They logged their food for three days and met with a nutritionist every few months — sometimes in groups and sometimes individually. They also did a cognitive training program that started with 10 group sessions and then progressed to self-paced computer-based brain training three times a week (10-15 minutes each day). Finally, they met with their physician every few months for consultations regarding the management of their chronic vascular and metabolic conditions. It’s important to note that the combination of multiple healthy behaviors is key, as previous studies with exercise, nutrition, or cognitive training alone have not demonstrated the same brain health benefits.

Although participation in such a program may be feasible—it does not require becoming an athlete and running a marathon—a critical consideration is the potential for widespread transfer of these types of interventions to clinical practice in the United States. It is true that the contact and support offered is much higher than what the average person receives from their health care team, at least in the US (where the average person with Medicare only sees their primary health care provider about 3 times a year). But having many touchpoints did not mean that all visits were made by the primary care provider—providing the intervention was truly a multidisciplinary effort; vascular/metabolic risk management visits were performed by physicians, exercise visits were performed by physical therapists, nutrition visits were performed by dietitians, and cognitive visits were performed or supervised by psychologists. Shared accountability for intervention delivery contributes to the feasibility of implementing such a program in a primary care setting.

An important and often overlooked consideration about this study is that these clinically significant improvements were seen in participants who had early cognitive problems and related comorbidities (this was part of their inclusion criteria). In fact, a secondary analysis of the results showed that even people with apolipoprotein E (APOE) allelic status. – the strongest known genetic risk factor for Alzheimer’s disease – maintained their cognitive benefits after participating in the program. There are indications of particularly beneficial effects in APOE carriers in terms of global cognition and memory, and ongoing studies are underway to investigate whether they benefit even more from this type of program. These findings are encouraging because they show that even in the presence of cognitive deficits, lifestyle improvements are an effective means of improving cognitive functioning and reducing the future risk of dementia. Those with early cognitive deficits are particularly good candidates for these types of lifestyle interventions, highlighting the need for greater access to practical cognitive screening solutions in primary care. Proactive screening for cognitive deficits is critical because they do not necessarily present during a routine office visit; many people do not raise these concerns with their healthcare team for a variety of reasons (denial and stigma, among others).

Reduction of hypertension, obesity and lack of physical activity with only 15% would prevent over 400,000 cases of dementia in the US. The transformative power of these results raises the question of how we can make the leap from good old-fashioned health advice to educating and supporting our patients to achieve brain-healthy lifestyles. We need to catch cognitive deficits early enough to do something about it. We must also find ways to expand our clinical workforce to support behavior change. My own recent work with colleagues shows that older adults are prepared to initiate healthy behaviors but do not always understand how to maintain them. Three critical components of successful behavior change that they lacked were: self-efficacy (the likelihood of continuing when faced with an obstacle), self-regulation (removing obstacles), and social support. In contrast, the biggest motivator was personalized advice – generic recommendations were specifically noted as a source of disengagement. Multicomponent interventions have many moving parts and will require creative approaches to increase coordination and communication among health care teams and provide the training and support needed to help people successfully navigate and maintain lifestyle changes.

Proactive health habits and early detection of cognitive problems are instrumental in maximizing the impact of lifestyle interventions on brain health. Emerging promising therapeutic targets are being tested, signaling hope for the near future in the fight against dementia. But, borrowing lessons from success in other areas of medicine, such as cancer therapies, the combination of successful therapeutic agents was required for optimal efficacy. Ideally, new therapeutics will be introduced in combination with lifestyle interventions, which will need to be customized for each individual and anchored in reliable, longitudinal indicators to allow for modifications as needed. So, regardless of the availability of new treatments, a holistic approach will offer the greatest potential for improving performance and, perhaps most importantly, preserving quality of life.

Photo: wildpixel, Getty Images

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