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Promising Strategies for the Prevention of Dementia

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Promising Strategies for the Prevention of Dementia NEUROLOGICAL REVIEW Promising Strategies for the Prevention of Dementia Laura E. Middleton, PhD; Kristine Yaffe, MD he incidence and prevalence of dementia are expected to increase several-fold in the coming decades. Given that the current pharmaceutical treatment of dementia can only modestly improve symptoms, risk factor modification remains the cornerstone for dementia prevention. Some of the most promising strategies for the prevention of de- Tmentia include vascular risk factor control, cognitive activity, physical activity, social engage- ment, diet, and recognition of depression. In observational studies, vascular risk factors— including diabetes, hypertension, dyslipidemia, and obesity—are fairly consistently associated with increased risk of dementia. In addition, people with depression are at high risk for cognitive im- pairment. Population studies have reported that intake of antioxidants or polyunsaturated fatty acids may be associated with a reduced incidence of dementia, and it has been reported that people who are cognitively, socially, and physically active have a reduced risk of cognitive impairment. However, results from randomized trials of risk factor modification have been mixed. Most prom- ising, interventions of cognitive and physical activity improve cognitive performance and slow cog- nitive decline. Future studies should continue to examine the implication of risk factor modifica- tion in controlled trials, with particular focus on whether several simultaneous interventions may have additive or multiplicative effects. Arch Neurol. 2009;66(10):1210-1215 By 2050, the number of people with Alz- indirect cost of dementia to society ex- heimer disease (AD) and other forms of tends beyond the direct cost and in- dementia in the United States is expected cludes lost productivity, increased absen- to almost triple. The predicted rise in de- teeism, and replacement expenses of mentia prevalence can largely be attrib- caregivers.1 uted to increasing longevity and the ag- Given the expected dramatic increase ing of the baby boomer generation. This in the incidence and prevalence of demen- shift toward an aging population is im- tia, the identification of successful pre- portant because the incidence of all- vention and treatment strategies is criti- cause dementia nearly doubles with ev- cal. However, the current pharmaceutical ery 5 years of age. treatment of dementia can only modestly Not surprisingly, the cost of caring for improve symptoms and cannot cure or pre- people with dementia will rise along with vent dementia. As a result, prevention of the prevalence. In 2008, the US Medicare dementia through risk factor identifica- cost for AD alone was approximately $91 tion and modification is of the utmost im- 1 billion. It is estimated that the cost of car- portance until disease-modifying agents ing for people with dementia will grow to 1 prove efficacious. If the onset of AD can $189 billion by 2015. Furthermore, the be delayed by 5 years, the expected preva- Author Affiliations: Departments of Psychiatry (Drs Middleton and Yaffe), lence would decrease by more than 1 mil- Neurology (Dr Yaffe), and Epidemiology and Biostatistics (Dr Yaffe), School of lion cases after 10 years and more than 4 Medicine, University of California, San Francisco, and the San Francisco Veterans million cases after 50 years.2 In this ar- Affairs Medical Center, San Francisco. ticle, we discuss some of the most prom- (REPRINTED) ARCH NEUROL / VOL 66 (NO. 10), OCT 2009 WWW.ARCHNEUROL.COM 1210 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Oxidative Insulin Adiposity stress resistance Diabetes Hypertension Dyslipidemia Dementia Obesity Endothelial Inflammation Subcortical dysfunction vascular disease Figure. Possible mechanisms that may explain the association between vascular risk factors and an increased risk of developing dementia. ising strategies for the prevention of dementia, includ- cholesterol and low-density lipoproteins in late life have ing vascular risk factor control, cognitive activity, physical an increased risk of cognitive impairment and dementia activity, social engagement, diet, and treatment of de- with stroke.7 This relationship has, however, been less pression. consistent than the relationship between hypertension or diabetes and dementia. In addition, several studies have PREVENTION STRATEGIES found that people who are obese in midlife and possibly later in life have an increased risk of developing demen- VASCULAR RISK FACTOR REDUCTION tia.6,7 Despite this relationship, people with dementia are more likely to have low body mass than be obese.6 How- Although AD and vascular dementia have traditionally been ever, low body mass may be a sign of frailty, which pre- viewed as distinct disorders, it is now generally agreed that disposes the person to AD, or may be an early symptom the two rarely occur in isolation. Both types of dementia of AD itself.6 share many risk factors and pathologic features with ath- Given the individual relationship of vascular risk fac- erosclerosis.3 In addition, the presence and severity of cere- tors with dementia and the frequency of their coexist- brovascular pathologic findings appear to increase the risk ence, it is not surprising that studies evaluating the effect and stage of AD for any given level of AD neuropatho- of multiple or composite vascular risk factors on the risk logic findings.3 Thus, the modification of vascular risk might of dementia have found that subjects who had diabetes, reduce the risk of dementia regardless of type. hypertension, or high cholesterol levels or were smok- Traditional cardiovascular risk factors such as hyper- ers at midlife were more likely to develop dementia later tension, dyslipidemia, and diabetes appear to increase the in life. The effects of each vascular risk factor were ap- risk of developing dementia in old age, with several pos- proximately additive.12 Similarly, the metabolic syn- sible mechanisms (Figure). More than 20 observa- drome, which is a clustering of disorders that include tional studies have shown that older adults with diabe- abdominal obesity, hypertriglyceridemia, low high- tes have approximately double the risk of developing density lipoprotein levels, hypertension, and/or hyper- dementia and mild cognitive impairment compared with glycemia, has been associated with an increased risk of those who do not have diabetes.4,5 Initial observations in- cognitive impairment and cognitive decline, especially dicated that diabetes was most strongly associated with in subjects with high levels of inflammation.12 the risk of vascular dementia, but more recent research Since people are more likely to have multiple vascu- has confirmed that people with diabetes also have a high lar risk factors than just one, it is difficult to establish risk of developing AD.6 mechanistic links between individual risk factors and de- Several observational studies have shown that people mentia. The mechanisms linking vascular risk factors to with hypertension in midlife consistently have in- cognitive impairment are likely numerous and complex creased risk of AD and all-cause dementia.7,8 In con- (Figure). The direct relationship between hyperten- trast, the association between late-life hypertension and sion, cerebrovascular disease (in its most severe case, dementia is more controversial. Both very high systolic stroke), and subsequent dementia is well established,11 blood pressure and very low diastolic blood pressure in and cerebrovascular disease is also likely to link obe- late life have been associated with increased risk of de- sity, diabetes, and dyslipidemia to cognitive impair- mentia and AD.9 However, other studies have found no ment. The degenerative changes in the cerebrovascular relationship between late-life hypertension and the risk vessels may also cause the dysfunction of both the en- of dementia.10 Some suggest that while hypertension is dothelium and the blood-brain barrier.11 Consequently, a risk factor for dementia, blood pressure may decrease endothelial cells may produce an excess of free radicals with the onset of AD.11 and cause subsequent oxidative stress with increased Other vascular risk factors also seem to increase the blood-brain barrier permeability to proteins leading to risk of dementia. People with high serum levels of total ␤-amyloid accumulation.11 (REPRINTED) ARCH NEUROL / VOL 66 (NO. 10), OCT 2009 WWW.ARCHNEUROL.COM 1211 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 There is also a growing body of work that suggests a slow cognitive decline.20 The benefit of cognitive train- direct link between insulin and AD pathologic findings. ing, however, seems to be domain specific. Several trials Specifically, in vitro studies indicate that insulin causes found that while cognitive training can improve memory, a significant increase in extracellular ␤-amyloid levels.6 reasoning, and mental processing speed in older adults,20 Consequently, people with insulin resistance, such as cognitive training did not generalize across domains and those with type 2 diabetes mellitus or those with precur- did not affect everyday functioning.21 In addition, el- sor hyperinsulinemia, may have insulin-caused in- derly people with memory impairment may be less able creases in ␤-amyloid levels. Furthermore, cholesterol is to make gains from memory training than those with- a key regulator of neuronal
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