Prevention of dementia: where are we now?

Dementia is a complex disorder and environmental and genetic influences interact to produce the disease. Causes of dementia include Alzheimer’s disease (AD), vascular dementia, mixed Alzheimer’s disease and vascular dementia, frontotemporal lobar degeneration, Parkinsons disease dementia and Lewy body dementia.

About 33.9 million people worldwide have AD, and prevalence is expected to triple over the next 40 years. One study published in 2010 found that delaying dementia onset by five years will reduce the 2040 prevalence by 37% and an onset delay of two years will reduce the prevalence by 16%.1

There is evidence on seven potentially modifiable risk factors for AD: diabetes, midlife hypertension, midlife obesity, smoking, depression, cognitive inactivity/low educational attainment, physical inactivity. Together, up to half of AD cases worldwide (17.2 million) and in the USA (2.9 million) are potentially attributable to these factors.

A 10–25% reduction in all seven risk factors could prevent as many as 1.1–3.0 million AD cases worldwide and 184,000–492,000 cases in the USA.2 AD incidence might also be reduced through improved access to education and use of effective methods targeted at reducing the prevalence of vascular risk factors.3

Delaying symptom onset by as little as one year could potentially lower AD prevalence by more than nine million cases over the next 40 years.

Studies to date suggest that a multifactorial intervention comprising regular exercise and healthy diet, along with the amelioration of vascular risk factors, psychosocial stress, and major depressive episodes, may be most promising for the prevention of cognitive decline. These strategies may show promise for the prevention of dementia at different stages of the disease.

Overall, evidence for preventing dementia is limited, and the exact role of these interventions warrants further examination by future studies.4

The strongest support from studies is seen for depression, (midlife) hypertension, physical inactivity, diabetes (midlife), obesity, hyperlipidemia and smoking. More research is needed for coronary heart disease, renal dysfunction, diet, and cognitive activity.5

Findings from the large, long-term, randomised controlled FINGER trial suggest that a multidomain intervention could improve or maintain cognitive functioning in at-risk elderly people from the general population.6

There is a growing consensus that the scientific evidence is now sufficient to justify policy action across the life course and for further research to reduce the modifiable risk factors and improve the population profile for recognised protective factors.7

In conclusion, prevention of dementia is now moving from observational to interventional studies to verify hypotheses and define tools that can be applied in the general population.

Since a cure for dementia is not yet available, finding effective preventive strategies is essential for a sustainable society in an ageing world.

Report based on a talk by Peter Passmore, Professor of Ageing and Geriatric Medicine, Queen’s University Belfast

 

1. Vickland V, et al. Dement Geriatr Cogn Disord 2010; 29: 123–30

2. Barnes DE, et al. Lancet Neurol 2011; 10: 819–28

3. Norton S, et al. Lancet Neurol 2014; 13: 788–94

4. Rakesh G, et al. Ther Adv Chronic Dis 2017; 8: 121–36

5. Deckers K, et al. Int J Geriatr Psychiatry 2015; 30: 234–46

6. Ngandu T, et al. Lancet 2015; 385: 2255–63

7. Lincoln P, et al. Lancet 2014; 383: 1805–80

 


The clinical burden of Oncology

Since 2010, the number of people living with cancer in the UK has grown by almost half a million people. This is largely due to improvements in survival and detection. Another impact is the ageing population, with the number of over-65s living with cancer increasing by almost a quarter (23%) in just five years.

Of the 2.5 million people currently living with cancer, 1.6 million were diagnosed five or more years ago. Yet, the longer a patient has cancer their needs become more complex. For example, they might experience side effects from the drugs, the impact of invasive surgery, or they need psychological support.

By 2020, half of Britons will get cancer in their lifetime and half will live at least 10 years, yet 38% will not die from the disease. There is a huge variation in outcome for different types of cancer.

Surviving cancer does not mean living well. As a result many needs go unmet. Almost three in four people living with cancer are in their survivorship stage.8 For many, the physical and emotional impact of their cancer experience hits home when the treatment is over. One in four of them have to deal with the consequences of their treatment9 and 20-30% of those cancer survivors consistently report problems associated with cancer and its treatment.10

People living with cancer have the same conditions as those of a similar age profile without cancer, but tend to have a higher prevalence of them. In people living with cancer in the UK in 2014, 42% had hypertension, 31% had obesity, 19% had chronic heart disease and 14% had diabetes.

There will be three times as many people aged over 65 years alive with cancer by 2040, which will amount to 4.1 million.11 By 2040, 77% of all living with a cancer diagnosis will be over 65 years and the most common will be breast and prostate cancer.

Older people with cancer fare worse often due to a combination of patient, clinical and service factors.

Patient factors include not realising that cancer risk increases with age and although most are willing to seek help, there is low awareness of services and they could be reluctant to ‘bother the doctor’.

Clinical factors include focusing on chronological not biological age; the desire to ‘do no harm’ versus ‘do some good’ and uncertainty over evidence.

In regard to service factors, many oncology teams do not have good links with geriatricians or primary care. Primary care may not provide useful information alongside referrals and, if they do, the information is often not used. Appropriate assessment does not take place and even if it does, there are poor links to services such as social services.

MacMillan has a geriatric oncology expert reference group that critically assesses the multiple explanations for poorer outcomes for older people affected by cancer. It also scopes whether an implementable assessment framework can be proposed by review of existing tools; examines and co-creates service improvement solutions and investigates workforce models to raise the profile of professionals with an interest in this field.

In conclusion, patients want it to be easy to get concerns heard and they want a quick diagnosis and timely treatment. Other outcomes that matter to people are planned stages of care with support, supported rehabilitation and aftercare. What is often not measured is the impact of treatment on independence, incontinence, impaired vision or hearing, impaired cognition and immobility.

Report based on a talk by Professor Jane Maher, Joint Chief Medical Officer, Macmillan Cancer Support

 

8. Maher J, McConnell H. New pathways of care for cancer survivors: adding the numbers. Br J Cancer 2011; 105: S5-S10

9. Figures quoted from expert consensus collated as part of Macmillan Cancer Support (2013)

10. Foster et al. Psychosocial implications of living with 5 years or more following a cancer diagnosis: a systematic review of the research. E J Cancer Care 2009. 18: 223–47

11. Maddams J, Utley M, Møller H. Projections of cancer prevalence in the United Kingdom, 2010–2040. British Journal of Cancer advance online publication

 


Bone health in the elderly patient

Secondary prevention of osteoporosis should be carried out in all those aged over 50 years who have had a low trauma fracture. To assess for primary prevention a risk score should be calculated using Q-fracture, which estimates 10-year risks of fracture (major osteoporotic fracture and hip fracture) from a number of risk factors. If risk is more than 10%, the patient should have a DXA scan and receive treatment if T score is more than -2.5.12

Bisphosphonates reduce bone turnover by decreasing the remodelling space and enhancing passive secondary mineralisation. They preserve bone function so that bone is stronger. In a technology appraisal last year, NICE assessed the cost-effectiveness of bisphosphonates for treating osteoporosis.13 The guidance stated that oral bisphosphonates (alendronic acid, ibandronic acid and risedronate sodium) are recommended as options for treating osteoporosis in adults only if the person is eligible for risk assessment as defined in NICE’s guideline on osteoporosis and the 10‑year probability of osteoporotic fragility fracture is at least 1%.14

Intravenous bisphosphonates (ibandronic acid and zoledronic acid) are recommended as options for treating osteoporosis in adults only if the person is eligible for risk assessment and the 10‑year probability of osteoporotic fragility fracture is at least 10%, or at least 1% and the person has difficulty taking oral bisphosphonates or these drugs are contraindicated or not tolerated.

It stated that the 10‑year probability of osteoporotic fragility fracture should be estimated using the FRAX or QFracture risk tools, in line with NICE’s guideline on osteoporosis.13

Combined calcium and vitamin D supplements are the best treatment for frail elderly patients living in residential/nursing homes and sheltered housing. They reduce the risk of hip and other fractures by a third15 and also reduce the risk of falls.16

A Cochrane review found that vitamin D alone, however, does not reduce the risk of fractures, but it probably does reduce the risk of falling and improves muscle function.17 In older communitydwelling women, annual oral administration of high-dose cholecalciferol resulted in an increased risk of falls and fractures.18

A recent study also tried to determine the effectiveness of high-dose vitamin D in lowering the risk of functional decline. It found that although higher monthly doses of vitamin D were effective in reaching a threshold of at least 30ng/mL of 25-hydroxyvitamin D, they had no benefit on lower extremity function and were also associated with increased risk of falls compared with 24,000 IU.19

Denosumab is a rapidly acting antiresorptive and its fracture data is very similar to IV zoledronic acid, but it is more convincingly effective in the over 75 years age group for hip fracture.20

Daily s/c teriparatide is a bone anabolic agent indicated for the treatment of osteoporosis in both men and women. According to one study, it increases skeletal mass, increases markers of bone formation and resorption, there is improvement in bone structure, it increases bone strength and it reduces risk of vertebral and nonvertebral fractures.21

In conclusion, guidelines exist, but some of them need clarifying and there is a good range of effective treatments.

Report based on a talk by Dr Mike Stone, University Hospital Llandough, Penarth, Vale of Glamorgan.

 

13. http://www.sign.ac.uk/guidelines/fulltext/142/

13. https://www.nice.org.uk/guidance/ta464

14. https://www.nice.org.uk/guidance/cg146/chapter/1-Guidance

15. Chapuy MC, et al. NEJM 1992

16. Pfeifer M, et al. JBMR 2000; 15(6): 1113-18

17. Avenell A, et al Cochrane Database Syst Rev 2014

18. Sanders KM, et al. JAMA 2010; 303(18): 1815–22

19. Bischoff-Ferrari HA, et al. JAMA Intern Med 2016; 176(2): 175-83

20. Papapoulos S, et al. Osteoporos Int 2015; 26(12): 2773–2783.

21. Saag KG, et al. N Engl J Med 2007; 357(20): 2028–39