Prevention in dementia

To mark Dementia Action Week, 16 May – 22 May, Comms Officer Henry Lockyer spoke with Dr Nicky Funnell, Clinical Director and Consultant Old Age Psychiatrist, SLaM, who shares how to lower your risk of developing dementia in later life.

Dr Nicky Funnell is Clinical Director and Consultant Old Age Psychiatrist, South London and Maudsley NHS Foundation Trust (SLaM), and Joint-Leader, King’s Health Partners (KHP) Mental Health of Older Adults and Dementia Clinical Academic Group (CAG).* She outlines below more information about dementia and the different ways it can be prevented and mitigated.

Nearly one million people are living with dementia in the UK and 55 million people worldwide. Sadly, this number is on the rise, with more families facing the devastating impact of dementia every year. Our age and genetics play a part in shaping our dementia risk and we can’t change these. But, research suggests that up to 40% of cases could be linked to risk factors we can influence. Looking after our hearts, regularly challenging our brains and staying connected to the people around us can help reduce our risk of developing dementia.

Is it a case of too little too late?

It’s never too early or late to start thinking about protecting our brains, and research shows that taking steps to improve our health in our 30s, 40s, and 50s can be especially important in helping lower our risk of developing dementia in later life - here are some of the actions you can take:

• Keeping blood pressure in check;
• Quitting smoking;
• Doing physical activity;
• Eating a balanced diet; and
• Drinking responsibly.

Love your heart, stay sharp, keep connected

• Love your heart - even slightly elevated blood pressure in middle age has been linked to a 30% higher risk of dementia two decades later. But taking blood pressure drugs may help avoid that risk, according to a study in the 19 May 2020 issue.
• Stay sharp – several studies, including one important project in Sweden that followed 800 women over 44 years, suggest that mental activity, as well as physical activity, in midlife could help protect brain health in later life. Researchers think that mental activity helps to build your ‘cognitive reserve’. This is your brain’s ability to cope and keep working, even in the face of damage from disease like Alzheimer’s.
• Keep connected – a major study in 2020 suggested that social isolation in later life could be a factor in around four percent of dementia cases. It’s not yet fully understood why this relationship exists though. While research does suggest that social isolation can increase dementia risk, it can also be a result of the very early stages of the condition, even if it hasn’t yet been diagnosed. Several studies have suggested a link between hearing loss and dementia risk too. Researchers, including Dr Piers Dawes at the University of Manchester, are now working to get to the bottom of whether hearing loss is a risk factor in itself, or if it could increase a person's risk of dementia by making it harder for them to stay connected to people and the world around them.

Too late once a diagnosis is made?

Dementia is not usually reversible, but there are some exceptions such as alcohol related brain damage and depressive pseudodementia. Looking after your brain and heart can still slow deterioration, and the acetyl choline esterase inhibitors – donepezil, rivastigmine and galantamine – can also give symptomatic improvements.

A new drug for Alzheimer’s disease, aducanumab, was controversially approved for use in the United States in June 2021 which supposedly targets the underlying cause of Alzheimer’s, rather than its symptoms, however the European Medicine Agency refused to approve the drug in December 2021, concluding that its potential benefits did not outweigh its risks.  

What does dementia prevention look like?

Preventing dementia can mean many things, including but not limited to:

• Help at home to prevent self-neglect and someone needing to go to a care home;
• Rationalising someone’s medication to prevent them falling and breaking their hip;
• Social prescribing to prevent someone from becoming depressed and deteriorating more rapidly;
• A door exit sensor to prevent someone from getting lost;
• Having a magi plug to prevent someone forgetting to turn off the taps from flooding their flat;
• Installing an extreme heat sensor to prevent a smouldering pan turning into a fire.

How are we helping?

The KHP Mental Health of Older Adults and Dementia CAG are leading publicly funded randomised clinical trials and have a programme to improve recruitment of our Memory Service patients into clinical trials to develop and improve treatment for older patients with mental health difficulties and dementia, in line with the Government’s Dementia Challenge.

Our work in dementia has identified novel biomarkers for diagnosis and progression monitoring, new treatment and effectiveness trials, for example developing new magnetic resonance imaging (MRI) markers based on the shape of the hippocampus to confirm diagnosis of Alzheimer’s disease at the earliest stage, and trialling potential course-modifying drugs in patients within our memory services. 

In addition, SLaM’s Psychological Medicine and Older Adults operational directorate provides several important services for adults of all ages who have dementia across south London. Here are some of the ways its tackling dementia:

• Delivering outreach to schools on dementia awareness;
• Improving physical health checks;
• Increasing dementia diagnosis rates from less than 50% to nearly 80% in the last decade;
• Establishing the brain health clinic, that includes early diagnosis of probable Alzheimer's disease, a virtual follow-up clinic, and apps such as ‘My MCI’ for patient tips and monitoring.
• Updating SLaM’s End of Life care policy, including the development of ‘preparing for end stage’ dementia booklets, which won the 2021 HSJ Patient safety award and has been nominated for the NHS Parliamentary Awards Excellence in Mental Health category.
• Developing the Medichec online tool to assess risk of anticholinergic burden (a strong predictor of cognitive and physical impairment) of taking one or more medications with anti, sedation and falls risk with medications.
• Reducing antipsychotic prescribing in dementia (prescribing antipsychotics to someone with dementia doubles the risk of stroke and death).
• Co-authoring a study that found urinary drugs with a high anticholinergic effect (tolterodine and oxybutynin) were associated with a 55% increased mortality risk in patients with dementia.**

As part of Dementia Action Week, Prof Dag Aarsland, Professor and Head of Department, Old Age Psychiatry, King’s College London, discussed the importance of biomarkers in diagnostic research of dementia, his experience working in the field over the last 30 years, and his aims to inform care for memory service users and clinicians in exciting new research projects. You can listen here.

*The KHP Mental Health of Older Adults and Dementia CAG brings together expertise from across the partnership, including world leading researchers in Parkinson's disease dementia/Dementia with Lewy bodies, the global epidemiology of older people’s mental health problems and the use of clinical informatics to inform research and service development.

**Anticholinergics (anticholinergic agent) are substances that block the action of the neurotransmitter called acetylcholine (ACh) at synapses in the central and peripheral nervous system.