Reducing the Impact of Dementia in America A Decadal Survey of the Behavioral and Social Sciences (2021) / Chapter Skim
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2 Prevention and Protective Factors
2 Prevention and Protective Factors
Pages 39-72
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From page 39... ...
.1 Identifying a firm percentage would be challenging, however, because dementia risk is associated with many factors beginning very early in life, 1 Modifiable risk factors account for an additional portion of the overall impact of dementia that is not explained by either identified genetic or identified environmental factors (Livingston et al., 2020)
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. These successful campaigns highlight the importance of targeting multiple levels of influence, as was done, for example, in the campaign to reduce smoking, which targeted both individual behavior (e.g., smoking cessation classes)
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First, it explores evidence about how various factors affect cognitive health and disease in individuals, including evidence about preventive strategies and policies that have been pursued in targeting chronic diseases that are medically linked to dementia, such as cardiovascular disease and diabetes. The chapter then turns to the evidence about broader social and environmental factors and policies that play a role in increasing or diminishing risk over the life span.
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From page 42... ...
INFLUENCES ON COGNITIVE HEALTH IN INDIVIDUALS Researchers have explored factors that may affect the risk of dementia directly, influences on cardiovascular health that in turn have implications for cognitive health, and other possible culprits. This section explores the evidence and reviews the implications for individuals and public health experts.
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. • Regularly discuss and review health conditions and medications that might influence cognitive health with a health care professional.
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, suggesting that shifts in risk factors have influenced dementia risk. The authors of the 2017 report coordinated their work with a systematic review commissioned by the Agency for Healthcare Research and Quality (AHRQ)
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From page 45... ...
Atherosclerosis in blood vessels in the brain, microbleeds, and silent strokes, for example, have been identified as contributors to dementia. It is possible that vascular risk factors increase dementia risk by other mechanisms as well (e.g., decreased blood flow in the brain may lessen the body's capacity to clear Alzheimer's disease proteins or increase their production)
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From page 46... ...
air pollution. These lifestyle behaviors are linked to the development of other diseases, particularly cardiovascular disease, and may also be linked to dementia risk.
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From page 47... ...
There are questions about whether some drug therapies themselves may be associated with that risk, even though they offer the benefits of treating a condition that increases dementia risk. Some drugs may also interact with dementia-related pathophysiological pathways by way of mechanisms unrelated to their original therapeutic indication.
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From page 48... ...
Cardiovascular disease in particular may contribute to dementia risk, and relationships among major chronic conditions, including hypertension, heart disease, and stroke, and dementia heighten the importance of attention to modifiable factors that affect risk.5 Use of Emerging Evidence to Promote Public Health The major challenge related to findings such as those reported above has been identifying ways to act on the evidence and change long-term behaviors, which may involve addictive substances or strong social norms and are constrained by built and social environments, as well as socioeconomic resources. There is little evidence to suggest that telling individuals to change their behavior will bring about enduring behavior change in most 5 https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Preventing-Stroke research
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. But in the context of health-related behaviors with possible implications for dementia risk, it is important to weigh a variety of competing considerations.
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The impact of such behavior changes on common risk factors could be substantial for a population, even if individual-level benefits were small. However, the population-level effects of behavior changes that reduce the risk of cardiovascular and other health conditions associated with dementia could also bring corresponding changes in population mortality risk.
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. The effects of these experiences will likely continue to contribute to racial disparities in dementia risk for years to come (see, e.g., Zuelsdorff et al., 2020; Coogan et al., 2020; Caunca et al., 2020)
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Growing up in poverty may also limit an FIGURE 2-1 Cumulative impact of risks and protective factors on cognitive health. NOTE: Note: Thearrows The upward upward arrows represent represent experiences experiences and exposures andhealth; that protect cognitive exposures thatarrows the downward protect cog represent risk factors that may impair it.
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From page 53... ...
Although much more work is needed to understand these issues, there is a growing body of work on three socioeconomic factors that influence dementia risk: education, occupation, and financial resources. There is also a growing literature on the role of race and ethnicity in disparities in dementia prevalence and incidence.
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. A study that explored the effects of changes in rules about compulsory schooling showed that individuals who completed more years of school had better cognitive outcomes and lower dementia risk decades later (Nguyen et al., 2016)
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Researchers have examined the effects of types of occupation, occupational autonomy, stress, and unemployment. For example, a study of work during midlife and later dementia risk found that mentally stimulating or complex work is associated with lower risk of dementia and may even compensate for the risks that come with lower educational attainment (Karp et al., 2009)
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From page 56... ...
The magnitude of racial/ethnic disparities in dementia risk and the heterogeneity of these disparities across subpopulations point to the potential impact of social and interpersonal experiences on people's risk for dementia. Multiple explanations for the disparities in dementia risk have been posited, many of which emphasize structural racism (Zhang et al., 2016; Plassman et al., 2007)
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From page 57... ...
The contrast in the mean years living with cognitive impairment or dementia after age 50 is stark: 3.9 years for Black women, 4.7 years for U.S.-born Latina women, and 6.0 years for foreign-born Latina women, compared with White women (1.6 years)
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. Policy makers also influence economic well-being, which, as discussed above, has an influence on dementia risk.
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. Limited access to high-quality health care may also have significant effects on cognitive health, as evidence on American Indian populations illustrates.
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Also needed is evaluation of initiatives that have begun to address such sources of inequality -- such as Seattle's Race and Social Justice Initiative, an effort to eliminate racial disparities and foster racial equity.10 Needed as well is study of the interactive, embedded, and reciprocal dynamics that operate in the relationships among patient, provider, community, service systems, and policy to identify additional pathways for mitigating the impact of institutional racism on cognitive health. RESEARCH DIRECTIONS A look across the landscape of preventive and protective factors suggests that a large proportion of dementia could be prevented or delayed, but there is limited rigorous causal evidence with enough precision to guide evidence translation and the development of interventions.
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To understand how to design interventions for any of these factors may require better understanding of mechanisms and mediators. To the extent that socioeconomic resources, such as education, do reduce dementia risk, these factors may well operate through behavior changes.
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6. Effective means of communicating the magnitude and degree of potential risk and protective factors to support informed decision making.
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From page 63... ...
, as well as of when in the life span they must be modified to have an effect • Studies of the extent to which the influence of socioeconomic resources or behaviors is dependent on context and capacity to utilize a resource • Research to improve understanding of how dementia develops across the life span and at what age the first behavioral or other manifestations emerge • Identification of study designs that can be used to evaluate alternative possible explanations for observational associations • Identification of the mediators/mechanisms linking social factors and dementia risk, in particular, mechanisms that might be modified • Where feasible, use of randomized controlled trial methodology in the study of behavior change and follow-up for dementia and related outcomes, ensuring that the methodology is sufficiently powered such that it involves large sample sizes, longitudinal interventions, and extended follow-up periods necessary to examine cognitive decline 3: Inequality in Dementia • Research on how interlocking systems of structural racism create disparities in dementia risk • Study of how the risk factors evaluated in typical research samples operate differentially in underrepresented groups • Examination of sources of resilience that reduce risk in individuals exposed to disproportionate, racially stratified risk factors • Exploration of the effects of individual, interpersonal discrimination on dementia risk and the mechanisms through which those effects may occur • Assessment of how promising interventions to delay or prevent dementia may affect disparities • Monitoring trends and progress in reducing disparities in dementia incidence, care, and outcomes Continued 63
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From page 64... ...
TABLE 2-1 Continued 64 4: Mechanisms Through Which • Study of the physiologic changes, behavioral patterns, social resources, and medical care mechanisms Socioeconomic Factors Operate underlying connections between socioeconomic factors and dementia risk 5: Interventions Involving Changes • Development and improvement of interventions to modify identified risk factors and reduce both the in Policies, Systems, or Individual overall population incidence of dementia and disparities in its incidence and outcomes Behaviors • Identification of critical elements of preventive factors that can be translated into policy interventions • Exploration of ways to redesign structural and environmental elements that shape the behavioral patterns of individuals (e.g., to improve access to exercise and healthy food) • Identification of the opportunity costs of proposed interventions 6: Effective Means of • Research on the tailoring of communication about the quality of evidence regarding suspected risk Communicating About Risk and factors to different communities to help individuals make informed decisions Protective Factors
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From page 65... ...
. Particulate air pollutants, APOE alleles and their contributions to cognitive impairment in older women and to amyloidogenesis in experimental models. Translational Psychiatry, 7(1)
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From page 66... ...
. Cognitive and social activities and long-term dementia risk: The prospective UK Million Women Study.
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From page 67... ...
. Mentally stimulating activities at work during midlife and dementia risk after age 75: Follow-up study from the Kungsholmen project.
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From page 68... ...
. Contribution of socioeconomic status at 3 life-course periods to late-life memory function and decline: Early and late predictors of dementia risk. American Journal of Epidemiology, 186(7)
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. Instrumental variable approaches to identifying the causal effect of educational attainment on dementia risk. Annals of Epidemiology, 26(1)
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. The neuropathology of probable Alzheimer disease and mild cognitive impairment.
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. Life course pathways to racial disparities in cognitive impairment among older Americans. Journal of Health and Social Behav ior, 57(2)
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. Stressful life events and racial disparities in cognition among middle-aged and older adults. Journal of Alzheimer's Disease, 73(2)
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