We need to become better at raising public awareness of how lifestyle factors can contribute to the risk of neurodegenerative diseases, says Alastair Noyce
Being a whiz at the cryptic crossword or Sudoku can induce a certain self-satisfaction. Yet more than that, as we get older, it provides some reassurance that our brains are healthy and even that we may be reducing our risk of developing dementia.1,2
There is a 10–20 year “window of opportunity” in midlife to potentially reduce the risk of neurodegenerative diseases or delay their onset through behaviour modification—including lifestyle changes.2-5 That window provides a key public health opportunity that we need to seize. Policymakers, public health professionals, and clinicians need to become better at incorporating messages about brain health into healthy living campaigns and programmes.
Recent campaigns have raised awareness of the contribution of lifestyle factors to the risk of cardiovascular diseases and cancer. Many people know that smoking, poor diet, and lack of exercise are bad for their heart. But the same factors are also bad for the brain.2,3
A large proportion of the general public believes that dementia and neurodegenerative diseases are an inevitable consequence of ageing.4 This is not true. Public health campaigns need to incorporate the simple and clear message that “what’s good for your heart is generally good for your brain,” and that the changes must be made earlier in life.2,6-8
A recent report, Time matters: a call to prioritize brain health, summarises published evidence and the conclusions of an international multidisciplinary expert forum of clinicians, researchers, health charities, and patient advocacy groups from across Europe and beyond. Focusing on the “big two” (Alzheimer’s disease and Parkinson’s disease), the report highlights that health systems are ill equipped to manage the growing number of people at risk of neurodegenerative conditions. At present, the treatments we can offer patients do not clearly slow the progress of disease,9,10 even if they ease symptoms.11-14
Most people are diagnosed years or even decades after the disease has started,15,16 a factor that has complicated the search for disease modifying treatments. After all, this high rate of late diagnosis means that clinical trials of potential therapies normally enrol individuals at a stage when disease is already advanced.
We clearly need new thinking and approaches to meet the challenge of neurodegenerative diseases—and more investment to fund research. Prevention strategies to limit the impact of these diseases hinge on research to identify effective biomarkers, tests for early diagnosis, and the development of novel and effective interventions. The approach to research should be international and multidisciplinary—we can achieve more together than we can separately.
To spread awareness of the message “what’s good for your heart is generally good for your brain,” GPs could start to introduce the concept of brain health into clinical consultations, by speaking with their patients about the behavioural and lifestyle recommendations for cardiovascular health that are also important for brain health.
The growth of consumer genetic testing poses risks and opportunities. Health professionals should be aware that an increasing proportion of the public are seeking information about their genetic risk of neurodegenerative diseases. We must agree a collective approach to assisting individuals who seek clarification about this information. At the same time, the use of genetic information offers the prospect of getting novel and targeted therapies to patients more quickly: new drugs supported by genetic evidence are two to three times more likely to be approved by regulators.17 This is an important consideration when potentially effective drugs risk failing in trials because they are being tested on “the wrong” patients.
Clinicians and campaigners should make the case to governments and funders of research that cost effectiveness will probably be delivered in the long run by reducing public expenditure on ever more patients with advanced stages of the diseases.
Neurodegenerative diseases pose an enormous socioeconomic and individual burden, and this will continue to grow as the population ages. Planning for the era of early diagnosis and more effective treatments has to start now if we are to avert a brain health crisis.
Alastair Noyce is a clinical senior lecturer in the Preventive Neurology Unit at the Wolfson Institute of Preventive Medicine, Queen Mary University of London. He was co-chair of the writing group for the report Time matters: a call to prioritize brain, which was published by Oxford Health Policy Forum CIC, a not-for-profit community interest company registered in England and Wales (Registration number: 10475240). Preparation of the report was funded by educational grants from Biogen and F. Hoffmann-La Roche, who had no influence on the content.
Competing interests: Nothing further to declare.
- Ngandu T, Lehtisalo J, Solomon A et al. A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial. Lancet 2015;385:2255–63.
- World Health Organization. Risk reduction of cognitive decline and dementia France, 2019. Available from: https://www.who.int/mental_health/neurology/dementia/guidelines_risk_reduction/en/
- National Institute for Health and Care Excellence. Dementia, disability and frailty in later life – mid-life approaches to delay or prevent onset 2015. Available from: http://www.nice.org.uk/guidance/ng16
- Alzheimer’s Research UK. Dementia Attitudes Monitor – Wave 1 Report 2018, 2019. Available from: https://www.dementiastatistics.org/wp-content/uploads/2019/02/Dementia-Attitudes-Monitor-Wave-1-Report.pdf
- Livingston G, Sommerlad A, Orgeta V et al. Dementia prevention, intervention, and care. Lancet 2017;390:2673–734.
- Alzheimer’s Australia. What’s good for your heart is also good for your brain: your brain matters. The Power of prevention, 2015. Available from: https://yourbrainmatters.org.au/sites/default/files/Whats-good-for-your-heart-is-also-good-for-your-brain.pdf
- World Health Organization. Global recommendations on physical activity for health. 2011.
- Norton S, Matthews FE, Barnes DE et al. Potential for primary prevention of Alzheimer’s disease: an analysis of population-based data. Lancet Neurol 2014;13:788-94.
- Mehta D, Jackson R, Paul G et al. Why do trials for Alzheimer’s disease drugs keep failing? A discontinued drug perspective for 2010–2015. Expert Opin Investig Drugs 2017;26:735–9.
- Cummings J. Lessons learned from Alzheimer disease: Clinical trials with negative outcomes. Clin Transl Sci 2018;11:147–52.
- Pink J, O’Brien J, Robinson L et al. Dementia: assessment, management and support: summary of updated NICE guidance. BMJ 2018;361:k2438.
- Fabbrini G, Brotchie JM, Grandas F et al. Levodopa-induced dyskinesias. Mov Disord 2007;22:1379–89.
- Kaakkola S. Clinical pharmacology, therapeutic use and potential of COMT inhibitors in Parkinson’s disease. Drugs 2000;59:1233–50.
- Crosby N, Deane KH, Clarke CE. Amantadine in Parkinson’s disease. Cochrane Database Syst Rev 2003:Cd003468.
- Noyce AJ, Lees AJ, Schrag AE. The prediagnostic phase of Parkinson’s disease. J Neurol Neurosurg Psychiatry 2016;87:871–8.
- De Strooper B, Karran E. The cellular phase of Alzheimer’s disease. Cell 2016;164:603–15.
- Nelson MR, Tipney H, Painter JL et al. The support of human genetic evidence for approved drug indications. Nat Genet 2015;47:856–60.