Lifestyle choices have an outsize influence on lives. In fact, from the humble common cold to cannibalistic cancer cells multiplying inside us, it’s our lifestyle choices — along with medical interventions when required, of course — that determine if we will lead a healthy life with our loved ones.
But the list of lifestyle ailments — already including the likes of diabetes, hypertension, cancer and cardiovascular complications — is always getting longer. And a recent entry to this league is dementia.
Researchers from the Institute of Health Metrics and Evaluation (IHME), an independent research unit of the University of Washington, along with global experts have recently suggested that global dementia cases (in those above the age of 40) would triple globally by 2050.
As per this forecast dementia cases could soar up to 153 million by 2050 globally from 57 million in 2019. At the moment dementia is rated the seventh leading cause of deaths worldwide and a major reason for dependency and disability among senior citizens.
What’s this got to do with people’s lifestyle choices? Well, one recent development in dementia care and management has been the worrying element of a sort of twinning happening between dementia and other lifestyle conditions through a series of modifiable risk factors including high blood glucose, obesity, smoking, hypertension and even air pollution.
This revelation has made researchers call out to experts on a global scale to ramp up clinical trials and research to decode and cure cognitive impairments, mainly dementia. Parallel efforts are also under way to give clear instructions to policymakers to design and promote region-specific low-cost intervention programmes, ranging from awareness to meticulous pharmacological interventions, to rein in dementia.
“We need to focus more on prevention and control of risk factors before they result in dementia,” says lead author Emma Nichols, Master of Public Health and researcher from IHME, University of Washington, in the report. “Even modest advancements in preventing and delaying dementia or delaying its progression would play remarkable dividends. To have the greatest impact, we need to reduce the exposure to the leading risk factors in each country. For most, this means scaling up locally appropriate, low-cost programmes that support healthier diets, more exercise, quitting smoking and better access to education. And it also means continuing to invest in research to identify effective treatments to stop, slow or prevent dementia.”
Dementia and external risk factors
In its Commission report published in 2020, the Lancet said that if exposure to 12 modifiable risk factors was eliminated then at least 40 per cent of dementia cases could be either prevented or delayed. (The 2017 list had been shorter — with excess alcohol consumption, traumatic brain injury and air pollution not been named as risk factors.) The 12 factors are:
- High blood pressure
- Midlife obesity
- Physical inactivity
- Social isolation
- Hearing impairment
- Head injury
- Excess alcohol consumption
- Air pollution
- Low education
In an online interaction with Happiest Health, Nichols pointed out that even policy-level decisions like imposition of sugar and tobacco tax by governments might positively impact dementia management. She also highlighted the need for improving general awareness and education among people about the condition.
“Our study included the effects of smoking, high blood glucose, obesity and low education, but other factors such as air pollution have been proposed as risk factors as well,” she said. “Both policy-level and individual-level changes will be important in addressing modifiable risk factors for dementia. Policies around educational reforms or air pollution can also help reduce the community-level exposures to risk factors.”
Neuropsychologist Dr Jayashree Dasgupta said dementia management should be implemented in a multipronged manner “with equal weightage for pharmacological and psycho-sociological strategies, especially when we have to take care of external risk factors”. Dr Dasgupta is co-founder of Samvedna Senior Care, an organization based in Gurugram, India, which provides care and support to those affected with dementia and their caregivers.
Nichols said that though the IHME report did not include hearing impairment, she acknowledged that hearing impairment was considered by many researchers to have a direct impact on dementia and is a proposed risk factor for the condition.
“Researchers hypothesize that hearing impairment affects cognition and dementia through mechanisms including changes to brain structure and function, increase in social isolation and increases in cognitive load,” Nichols said. She also pointed out that more cognitive resources are required for hearing so fewer are available for other tasks to explain how hearing impairment could prove to be a risk factor for dementia.
Dr Dasgupta told Happiest Health that even often-overlooked factors like hearing impairment in senior citizens above the age of 60 if left unaddressed could eventually trigger a sense of isolation and depression, which are all listed as external risk factors. She said that sensory impairments often result in brain and neural exertion which is considered to have an adverse effect on the cognitive capabilities of the elderly.
The Global Burden of Disease (GBD) study and the dementia projection report states that academic advancements and community- and individual-level interventions through education are expected to reduce the prevalence of dementia in 2050 by at least six million across the globe. But it also says that this dip in global cases would get nullified because of another seven million dementia cases predicted by 2050. And these additional cases have been mainly attributed to modifiable and lifestyle risk factors — mainly high blood glucose, obesity and smoking. The IHME study also mentions that dementia management is literally exerting an additional financial burden of $1 trillion across the world.
Dr Dasgupta said that factors that cause internal systemic inflammation — like insulin resistance and other vascular changes — often lead to adverse effects on cognitive functions, ultimately with a higher chance of ending up with conditions like dementia. Systemic inflammation triggered by the body’s internal immune network, often due to external factors, is the root cause of almost every lifestyle vascular complication, which ultimately ends up linking cognitive impairments, especially dementia, to these lifestyle conditions.
Big surge projected in Arab countries
The forecast report has also pointed out that with the available data and research carried out, it has been predicted that the sub-Saharan Africa and the Middle Eastern region will have the maximum projected increase in dementia cases. Qatar (1,926%), the UAE (1,795%) and Bahrain (1,084%) are among the Gulf countries that could witness the biggest upward surge in dementia cases.
Nichols said that demographic shifts due to changes in population and effect of ageing on these population figures played a major role in determining the high or low percentage of dementia projections in most of the countries. “In countries like the UAE, Oman or Qatar, expected growth in the population coupled with anticipated shifts in population ageing lead to large projected increases. In contrast, Japan’s population is expected to decrease, and there will be less of an effect of population ageing,” Nichols told Happiest Health.
She said that according to the findings of the report, there will be 197 per cent increase in the number of dementia cases in India by 2050 and the total number of individuals affected with the condition is expected to be around 11.4 million. Countries with a high number of senior citizens and also at a greater risk from the modifiable risk factors are being urged to be proactive in their efforts to control and curb dementia.
Early detection and ensuring care and support
Dementia is an umbrella term under which a series of neurological and cognitive impairments that are more or less associated with ageing get listed. According to Mayo Clinic, dementia is a generic term for conditions like Alzheimer’s, vascular dementia, lewy body dementia, frontotemporal dementia and even mixed dementia (senior citizens affected with a combination of Alzheimer’s and other cognitive impairments like vascular dementia).
It is also believed that all these versions of dementia could be interlinked and one could advance into another, putting the individual at a higher risk. An example would be the case of those with vascular dementia, which is mainly due to complications in blood supply to the brain that ends up affecting neural transmissions. This could also lead to a higher risk of strokes in these people. Multiple strokes could further deteriorate neural functioning and the cognitive condition could advance into Alzheimer’s or other serious versions of dementia.
“Other than Alzheimer’s, vascular dementia is very common in India because of increased risk of diabetes, hypertension and cardiovascular diseases leading to strokes,” said Dr Mahendra V Javali, neurologist and associate professor, Department of Neurology, MS Ramaiah Memorial Medical College and Hospital, Bengaluru.
Dr Javali pointed out that people either 65 or above should be screened for cognitive impairments even if they don’t have any visible symptoms. However, despite the advancements made in medical and research sectors, dementia still continues to be an undetected condition in a large number of people. Expert intervention is often sought only after the patient slips into an advanced stage in which the only option available is to ensure that the affected person is made to feel as comfortable as possible with personal care and minimum medical intervention (sedatives whenever required as recommended by a medical expert).
“It is unsettling that the majority of dementia cases come before experts only in its advanced stage. I would point out that in about 90 per cent of dementia cases, the onset and early-stages progress completely unnoticed and medical advice is sought much later,” Dr Dasgupta said.
She gave the example of a dementia awareness and screening camp for senior citizens conducted by her organization in New Delhi in 2019, a couple of months before the Covid-19 pandemic. Out of the 200 people screened at the event, at least four per cent were found to have signs of cognitive impairment which neither they nor their family members had been aware about until then.
“The most worrying factor is that most of these people were from middle- and upper-middle-class background, from families where almost everyone is well educated and aware about conditions like dementia that could affect senior citizens,” she said
Dr Dasgupta said that in the majority of people who end up with cognitive impairments once they cross their sixties, subtle signs of cognitive impairment start becoming visible during their middle age itself (late 40s). It could take decades for them to plunge into an advanced stage of dementia and with early diagnosis and intervention further deterioration could be either prevented, prolonged or better managed for the rest of their lives.
“Any cognitive change from the baseline should be evaluated, like difficulty in managing finances, finding it difficult to choose the right word to speak, managing complex tasks along with impairment,” Dr Javali said when asked about the early and often-overlooked symptoms of the condition.
Sudden reclusive behaviour (both at home and work), temper tantrums, inexplicable drop in productivity, skipping office meetings without valid reasons and constantly creating embarrassing situations for themselves, colleagues and family members feature among these early warning signs that often escape the dementia radar.