In the past decade, important strides have been made in the fight against dementia. A critical win in this context has been the debunking of the notion that cognitive decline and dementia are a natural part of getting older. Current evidence indicates in fact 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 groundbreaking prospective interventional study by Finnish scientists that found that a two-year brain health program targeting lifestyle improvements was effective in reducing dementia risk by 30% when compared to good old-fashioned health advice. Participants in the study 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 an improvement in their overall mental sharpness of 25% (their memory was 40% better, their brain was 150% faster at doing mental tasks, and their problem-solving ability was also up by 80%). While 30% may not seem like a large reduction in dementia risk, it is worth noting that this is better than any currently approved drug we have for treating dementia. A crucial piece here is that this was the first prospective randomized controlled study of its kind, thus establishing causality between participating in a program targeting multiple brain healthy behaviors, and dementia risk reduction and mental sharpness improvement.
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While these results are certainly exciting, what is most surprising about this study, as with others like it, was that the activities and program schedule were arguably pretty 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 began with 10 group sessions, and then progressed to a self-paced computer-based brain training three times per week (10-15 mins each day). Lastly, they met with their physician every few months for counseling on managing their chronic vascular and metabolic conditions. It is important to note that the combination of multiple healthy behaviors was key, since prior studies with exercise, nutrition, or cognitive training alone did not demonstrate the same benefits for brain health.
While participation in such a program was arguably doable – it didn’t require becoming an athlete and running a marathon – a critical consideration is the potential for broad translation of these types of interventions into clinical practices in the US. It is true that the contact and support offered is much higher than the average person receives from their healthcare team, at least in the US (where the average person with Medicare only sees their primary healthcare provider about 3 times a year). But having many touchpoints did not mean that visits were all done by the primary care provider – the intervention delivery was a truly multidisciplinary effort; vascular/metabolic risk management visits were done by physicians, exercise visits were done by physical therapists, nutrition visits were done by nutritionists, and cognitive visits were either done or overseen by psychologists. The shared accountability in the intervention delivery adds 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 meaningful improvements were seen in participants who had early cognitive problems and associated comorbidities (this was part of their inclusion criteria). In fact, a secondary analysis of 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 participation in the program. There were indications of particularly beneficial effects in APOE carriers in terms of global cognition and memory, and current studies are being conducted to investigate if they benefit even more from this type of program. These findings are encouraging because they show that, even in the presence of cognitive deficits, improvements in lifestyle are effective means to improve cognitive functioning and reduce future risk of dementia. Those with early cognitive deficits are particularly great candidates for these types of lifestyle interventions, highlighting the need for greater access to practical cognitive screening solutions in primary care. Proactive screening of cognitive deficits is critical because they don’t necessarily come up in a routine office visit; many people do not bring up these concerns to their healthcare team for various reasons (denial and stigma, among others).
Lowering hypertension, obesity, and physical inactivity by as little as 15% would prevent over 400,000 cases of dementia in the US. The transformative power of these results begs the question of how we can take the leap from good old-fashioned health advice to coaching and supporting our patients to achieve brain healthy lifestyles. We need to catch cognitive deficits early enough to enable us to do something about it. We must also find ways to extend our clinical workforce to support behavior change. My own recent work with colleagues demonstrates that older adults are prepared to start a healthy behavior, but don’t always understand how to keep it going. Three critical ingredients of successful behavior change they lacked were: self-efficacy (the likelihood to keep going when faced with an obstacle), self-regulation (troubleshooting obstacles), and social support. In contrast, the highest motivator was personalized advice – general 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 healthcare teams and deliver the coaching and support needed to help people successfully navigate and maintain lifestyle changes.
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Joyce Gomes-Osman Joyce Gomes-Osman, PT, PhD is Vice President of Interventional Therapy at Linus Health, and a Voluntary Assistant Professor of Neurology at University of Miami Miller School of Medicine.
Proactive healthy habits and early detection of cognitive issues are instrumental in maximizing the impact of lifestyle interventions on brain health. Emerging promising therapeutic targets are being tested, signaling hope in 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 necessary for optimal efficacy. Ideally, novel therapeutics will be introduced in combination with lifestyle interventions that are going to need to be personalized to each individual, and anchored in reliable, longitudinal metrics to enable modifications as needed. So, regardless of the availability of new treatments, a holistic approach will offer the most potential for improving effectiveness and, perhaps most importantly, preserving quality of life.
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Joyce Gomes-Osman, PT, PhD is Vice President of Interventional Therapy at Linus Health, and a Voluntary Assistant Professor of Neurology at University of Miami Miller School of Medicine.
