It is time to reset expectations about our cognition as we age, for ourselves as individuals and for our country. Alzheimer’s remains at the top of the most feared list among retirees—above cancer and COVID-19—and nearly half of middle-age American’s think they are likely to develop dementia. Yet contrary to what most believe, cognitive decline is not inevitable, and there are steps we can take now to build our personal and collective brain health resilience.
Research demonstrates we can reduce the risk of Alzheimer’s and other dementias. The Lancet Commission found that up to 40 percent of dementia cases could be delayed or prevented by modifying 12 risk factors—less education, hypertension, hearing impairment, smoking, obesity, depression, physical inactivity, diabetes, low social contact, excessive alcohol consumption, traumatic brain injury and air pollution.
Hundreds of other studies over the past decade demonstrate there are steps that individuals, communities and public health systems can take now to reduce the risk of dementia and Alzheimer’s. These steps are good for overall health and have positive impacts against not just dementia, but against other co-occurring conditions like diabetes, hypertension and obesity. In addition, many of these comorbidities in patients with dementia are also demonstrated risk factors for COVID‐19.
Unfortunately, despite there being actions we can take to reduce risk; in the United States we are not taking them. One study showed only 5 percent of those who believed they were at risk for dementia raised the issue with a healthcare provider, and less than 50 percent of adults are physically active or maintain a healthy diet.
Many people still believe they are predestined by family history to have dementia or Alzheimer’s. We now know that family and genetic history are risk factors, not determining factors. Gene expression is controlled in large part by our habits, and lifestyle interventions, such as physical activity, diet and managing chronic conditions such as diabetes and hypertension, can make a difference.
Individuals Alone Cannot Solve the Problem
Changing the trajectory of the dementia pandemic will require both individual and government action, however, and our social and health systems are not making it easy for us to live brain-healthy lives. COVID-19 has revealed the fault lines in our public and clinical health system. Underserved communities in particular face social determinant hurdles such as racism, lack of housing and access to care. Black Americans are two times more likely and Latinos one and a half times more likely to develop Alzheimer’s than are white Americans.
Social determinants of health pose a veritable obstacle course of barriers to dementia prevention.
Healthcare providers fail to discuss brain health with patients, particularly risk reduction opportunities, and even when patients express memory concerns, fewer than 16 percent of them receive a regular validated cognitive assessment. Tack on limited access to healthy food, safe places to walk, education and mental health supports, and it’s a veritable obstacle course of barriers.
For all of these reasons, more than 185 organizations and experts, including the American Society on Aging, Volunteers of America, American Heart Association, the National Urban League, YMCA of the USA, AARP, UnidosUS, the National Kidney Foundation, HADASSAH, the Milken Institute and others are calling for a national dementia prevention goal and a plan to reach that goal.
The Federal Advisory Council on Alzheimer's Research, Care and Services recently recommended the Secretary of Health and Human Services (HHS) update the National Plan to include development of a more accountable national prevention goal. The Secretary failed to include this provision in the 2020 National Plan update. Despite this, the Advisory Council is pursuing this work in the hopes of including it in the 2021 National Plan. To succeed, this effort will require strong Congressional and White House support and should be a top priority for the Biden Administration and the new Congress.
An accountable national prevention strategy to reduce dementia risk offers a unique opportunity to mobilize clinical, policy and public health efforts that not only stem the tide of dementia but also reduce diabetes, hypertension, tobacco use and depression, among other risk factors, particularly in communities of color.
The Return on Action Is Enormous
The Department of Health and Human Services has the opportunity to encourage providers and payers to proactively address brain health among non-symptomatic, healthy older adults and to strengthen early detection and interventions that delay disease progression. We should harness the financing power of Medicare and Medicaid to incentivize risk-reduction within the healthcare delivery system.
We should strengthen our public health system, particularly the CDC’s efforts to address chronic conditions and support healthy aging. We should fill gaps in the evidence base, take a life-course, multi-domain approach, and inform population health approaches that improve the brain-health of whole communities.
The return on such action would be enormous. A five-year delay in dementia onset would cut dementia prevalence in half. Also, if achieved by 2025 by 2050 it would reduce total healthcare payments 33 percent and out-of-pocket payments 44 percent.
Without intervention, by 2050 the number of Americans with dementia will triple. Women bear the largest burden with two-thirds of the cases, and Latinos and Black Americans will see the largest increases. The Economist stated it unequivocally: “dementia is a global emergency” and governments should act now.
We, too, as individuals have some agency, and it should offer hope that while a treatment has so far been elusive, we are not powerless in the fight.
Kelly O’Brien is executive director of the Brain Health Partnership at UsAgainstAlzheimer’s in Washington, DC.