Intensive interventions for dementia prevention generally focus on those considered ‘high risk,’ – but what happens when nearly everyone over 65 could fit that description?

Writing in Nature Reviews Neurology last week, UNSW’s Ageing Futures Institute director Professor Kaarin Anstey, and population health researcher and epidemiologist Dr Htet Lin Htun argue that’s exactly what’s happening – and it’s time to rethink our approach.

Dr Htun and Professor Anstey cite research across multiple countries showing that more than half of middle-aged adults had at least two modifiable risk factors – and often far more – with similar findings reported in Australia. They note that while that evidence was based on 12 established risk factors, a Danish study that looked at 16 modifiable risk factors found just 5% of nearly 90,000 adults aged 65 or older had no dementia risk factors.

“Across demographically and economically diverse populations, a low-risk profile therefore appears to be the exception rather than the rule,” Dr Htun and Professor Anstey write.

Risk factors accumulate over the life course, with multiple risk factors in mid-life and beyond amplifying risk. Moreover, as the number of recognised risk factors grows, “the high-risk group increasingly overlaps with the population as a whole rather than representing a clearly separable minority,” Dr Htun and Professor Anstey say.

They say intensive, multi-domain interventions should still be targeted at those at the highest risk, such as people with mild cognitive impairment or subjective cognitive decline, but “we question whether dementia prevention should continue to be framed around a dichotomy that is no longer fully supported by epidemiological evidence while population-level approaches receive comparatively little investment and evaluation.”

Dr Marita Long, medical advisor at Dementia Australia, says dementia risk reduction is crucial across the life span – and needs to be optimised for everyone.

That involves identifying someone’s risk factors, considering which ones they can realistically address, using motivational interviewing and shared decision-making, and following up.

“Some of this can be done opportunistically during ordinary consultations,” Dr Long notes, “but meaningful prevention also needs adequately funded time.”

Practical tools such as CogDrisk can help GPs tailor a plan.

“Rather than simply telling someone they are ‘at risk,’ we can identify strengths as well as areas where change may help, and work together on an individual plan,” Dr Long says.

As more people become aware that things like managing their blood pressure, being physically active, not smoking, and being social are good for their brain as well as their overall health, the easier it will be for GPs to support them and personalise a public health message, “rather than having to introduce the entire concept in a 15-minute consultation,” she adds.

Read more

Major update to WHO’s dementia risk reduction guidelines