<strong>The Lancet Commission Once Again Validates Multidomain Interventions for Dementia Prevention and Care</strong>

The Lancet Commission Once Again Validates Multidomain Interventions for Dementia Prevention and Care

By Dr. John Q. Walker & Susan Pearsall

Highlights from the report produced by the third Lancet Commission on Dementia Prevention, Intervention, and Care were presented on 31 July at the 2024 Alzheimer’s Association International Conference (AAIC). Previous commission reports in 2017 and 2020 also argued for preventive strategies that target modifiable risk factors associated with cognitive impairment. The 2024 report expands the list to 14 health factors that are potential targets for preventive measures:

  • cardiovascular disease, especially hypertension
  • low level of childhood education
  • physical inactivity
  • social isolation
  • smoking
  • depression
  • diabetes
  • obesity
  • excessive alcohol consumption
  • traumatic brain injury (TBI)
  • exposure to air pollution
  • hearing impairment
  • vision impairment
  • high LDL cholesterol

As in years past, the 2024 Lancet Commission report draws on meta-analyses of hundreds of peer-reviewed studies and emphasizes prevention due to the lack of effective pharmacological treatments. The research concludes that “The potential for [dementia] prevention is high and, overall, nearly half [45.3%] of dementias could theoretically be prevented by eliminating these 14 risk factors” (1).

However, the Lancet Commission continues to omit two factors we see daily, and that we think should head their list:  polypharmacy and multimorbidity. We daily see people on dozens of medications, with potentially hundreds of active, clinically-significant drug-to-drug interactions.  This panoply of medications causes brain fog (anticholinergic cognitive burden) and increases the risk of potentially catastrophic falls. Critically, 80% of those we see also have three or more chronic diseases.  We recommend accounting for these complexities and addressing them systematically.

In the United States, approximately 6.9 million individuals live with Alzheimer’s disease (AD), the most common form of dementia (2). The Alzheimer’s Association estimates that nearly 11% of Americans 65 and older have AD (2). AD often coexists with other types of dementia, such as vascular dementia (2). The presence of these additional health factors increases the complexity of assessing and treating these individuals. And AD is itself a highly complex condition, involving genetic factors that exacerbate the effects of the environmental, health, and lifestyle factors highlighted by the Lancet Commission.  

The authors assert that dementia prevention is a lifelong pursuit and that “it is never too early or too late to reduce dementia risk” (1). From a population-based perspective, dementia is costly for individuals, families, and societies. A recent study found that public health initiatives targeting even half of the modifiable risk factors could save billions annually (3). However, applying public health findings to individual care remains challenging. Family physicians still bear the brunt of AD diagnosis and care. A growing shortage of neurologists means that primary care is still the locus of dementia prevention and treatment.

The Lancet Commission authors assert that “Multidomain interventions [that] address multiple dementia risk factors through health-related and behavioral changes” are “appropriate” (1). At uMETHOD Health, our extensive work in this area provides powerful evidence that supports personalized, multidomain interventions for dementia prevention and care.

uMETHOD’s RestoreU comprehensive care plans offer extensive personalization, addressing risk factors often overlooked by most multidomain intervention programs and improving adherence, which is crucial for effectiveness. The success of Dean Ornish’s anti-AD lifestyle intervention indicates that higher-intensity training with a high degree of personalization can yield a significant effect in only 20 weeks (4). Other trials of multidomain interventions with significant effect sizes include the SMARRT Trial and the FINGER Study, both of which included personalization (5) (6).

Personalized multidomain care plans that address as many of an individual’s dementia risk factors as possible are likely to be the most effective strategy for both prevention and care. As Ornish has also found, an expensive, inpatient model is not required. At uMETHOD Health, we deliver a physician-administered dementia-care program that is rapidly scalable, easily adopted, and cost-effective, leveraging software to walk a practitioner and patient through the steps to address all risk factors simultaneously.

References

1. Livingston, G et al. Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission. Lancet. 2024, Online: 31 July 2024.

2. Alzheimer’sAssociation. 2024 Alzheimer’s Disease Facts and Figures. Alzheimers Dement. 2024, Vol. 20, 5.

3. Mukadam, N et al. Benefits of population-level interventions for dementia risk factors: an economic modelling study for England. The Lancet Healthy Longevity. 31 July, 2024.

4. Ornish, D et al. Effects of intensive lifestyle changes on the progression of mild cognitive impairment or early dementia due to Alzheimer’s disease: a randomized, controlled clinical trial. Alzheimers Res Ther. Jun 7, 2024, Vol. 16, 1.

5. Yaffe, K et al. Effect of personalized risk-reduction strategies on cognition and dementia risk profile among older adults: the SMARRT randomized clinical trial. JAMA Intern Med. 184: 54-62, 2024.