Prevent before you’re bound to treat

Dementias threaten to topple economies as the cost of treatment skyrockets. An Israeli proposal to proactively find those who are at risk for Alzheimer’s could make a difference.

Many people regard Alzheimer’s disease and other dementias of old age as being impossible to prevent or treat and more frightening than cancer, with sufferers gradually and irreversibly losing their identity and slipping into oblivion.
While dementia can be a devastating disease, few people – even physicians – are aware that about half of all cases can be prevented with lifestyle changes. These include both objective (“upstream”) factors, such as quitting smoking, controlling blood pressure, lowering alcohol consumption, losing weight and exercising, as well as subjective (“downstream”) factors, such as by reducing loneliness, stress, meaninglessness and depression.
Half of all deaths in the US are due to preventable behaviors and exposures. Some 400,000 Americans die each year due to poor diet and a sedentary lifestyle. Treating the downstream factors has been found to be five to 10 times more effective than dealing with the upstream factors.
The US medical system spends 88 percent of its budget on medical services only and just four percent on prevention. In Israel, less than two percent of the health budget goes to prevention.
DR. YAKIR Kaufman, a senior neurologist and director of the neuro-psycho-geriatric department of Jerusalem’s Herzog Medical Center, regards dementias as the plague of the 21st century. It threatens to topple economies around the world (including Israel’s) due to the hundreds of billions of dollars a years that it costs to treat long-living victims.
Because of his efforts, Kaufman was recently invited by the World Federation of Neurology and the American Academy of Neurology to participate in an international videoconference and speak to counterparts from Europe, America, Asia and Africa, including representatives from China, Cuba, Jordan, Senegal, Russia, Albania, Sudan, Uganda, the Palestinian Authority, Egypt and Saudi Arabia.
His hour-long lecture, based on a variety of studies, was called: “Yes We Can! Primary Prevention of Alzheimer’s Disease.” Herzog regular participates in such videoconferences held under the auspices of the Canada International Scientific Exchange Program.
Among the subjective, psychosocial factors promoting dementia are the lack of mentally stimulating behavior, being forced to retire and being inactive (instead of doing other paid work or volunteering) and being socially isolated. Postponement of mandatory retirement, said Kaufman, would be beneficial.
“Physicians who treat individuals who lose jobs as they near retirement should consider the loss of employment a potential risk factor for adverse vascular health changes,” said a published study.
“Policy makers and program planners should also be aware of the risks of job loss, so that programmatic interventions can be designed and implemented to ease the multiple burdens of joblessness.”
Kaufman proposed “proactive, door-to-door screening of people for objective and subjective risk factors, creating a professional network of “brain wellness centers” on a local and regional basis.
“Create occupational/ volunteer centers and community social, physical, occupational and cognitive stimulation centers,” he proposed.
“Screen for stress, loneliness, meaninglessness, smoking, body-mass index. Alcoholism, low physical activity, low cognitive stimulation, metabolic and cardiovascular risk factors and polypharmacy (taking a large number of medications, including superfluous ones significantly raises the risk of dementias.
“Taking 10 different drugs or more means a much higher risk of developing dementia,” he added.
“There are few incentives for physicians to prevent dementia by keeping patients well,” said the neurologist. “Doctors are used to treating diseases instead. They should receive incentives for keeping their patients healthy because they are saving the public health system a large amount of money.”
In some US states, he said, individuals who stop smoking or – as shown on their pedometers walk 10,000 steps a day – reduce their risk of diseases get a discount on their health insurance payments.
KAUFMAN, WHO is writing a position paper on the subject with public health experts, urges the Health Ministry and other government offices to intervene. Instead of just screening elderly populations for dementia, he suggests that senior ministry officials go into the community of elderly and even middle-aged individuals and identify objective and subjective risk factors early before they develop dementias.
“Israel could become a world pioneer in this field,” said the Orthodox neurologist, who nine years ago published his own landmark study showing that spirituality and religious practice delay the onset and slow the progression of Alzheimer’s.
“Dementia is one of biggest challenges – threats – in world today,” he said in his lecture, with 35 million people currently suffering from it.
“We are looking for the ‘key under the lamp’ – some ‘wonder pill’ to treat dementias [TIME magazine recently ran a cover story on a wished-for Alzheimer’s pill], but I don’t think we’ll find it. There are lots of statistically significant, but clinically irrelevant, studies on it, and we are involved in intervention rather than prevention.”
At the G-8 summit on dementia – which was held in London in 2013 and was presided over by World Health Organization secretary-general Dr. Margaret Chan – government ministers, researchers and representatives of pharmaceutical companies and charities around the world heard that the number of sufferers is due to double every two years. This might stimulate greater investment and innovation in dementia research. The present annual cost of dementia to world economies is $600 billion.
The direct cost of treating each patient for a year is $50,000 to $70,000.
“Societies will become bankrupt if we don’t think out of the box,” said Kaufman, who attended the London event.
“We haven’t been doing this.
The challenge is to turn one of the greatest threats into one of the greatest achievements, as was the turning of HIV into a chronic instead of a terminal disease.”
A 10% to 25% reduction in all the risk factors could potentially prevent 1.1 million to 3 million Alzheimer’s cases worldwide, thus saving $100 billion a year.
TWO DIETS – the Mediterranean Dietary Approach to Systolic Hypertension (DASH) and the Mediterranean Intervention for Neurogenerative Delay (MIND) – have been shown to protect the brain and delay dementia for an average of 4.7 years. The MIND diet was positively associated with a slower decline in the global cognitive score – thus substantially slowing cognitive decline with age.
Midlife obesity is especially associated with an increased risk of dementia, but – ironically, some fat in later life can actually be protective.
The more low-risk factors one has – such as no smoking, normal weight and high physical activity, the lower the risk of dementias, according to studies quoted by Kaufman.
“These findings show that prevention is possible, and that it’s good to start early.”
Kaufman added that “it is never too late” to have benefits from lifestyle changes, not only by lowering the risk of dementias but also by slowing it and reducing the severity when the patient is already diagnosed with it.
“There is no maximum age for prevention. It is important even for secondary and tertiary prevention, even within the disease. Even spiritual wellbeing can be helpful,” said the Herzog neurologist.
One study Kaufman quoted found that “feeling lonely rather than just being alone is associated with an increased risk of clinical dementia in later life and can be considered a major risk factor that, independently of vascular disease, depression and other confounding factors. This deserves clinical attention.
Feelings of loneliness may signal a prodromal stage of dementia. A better understanding of the background of feeling lonely may help us to identify vulnerable persons and develop interventions to improve outcome in older persons at risk of dementia.”
Amazingly, having a negative image of old age – that it means only illness and infirmity – when one is young raises the risk of developing dementias when one becomes old.
“When they became older, their brain was more atrophied, with more tangles and plaques in the brain. This is the prophesy that actually came true. If we change attitudes to elderly at all ages, we may be able to prevent or delay atrophy of brain.”
“I think it is urgent that the government launch a pilot project to see how the proposals work. My colleagues and I are using a model in Sderot in the South, and then we will proceed to Kiryat Shmona in the North.”
Asked for comments on Kaufman’s proposals, the ministry representative did not allow The Jerusalem Post to discuss it with public health chief Prof. Itamar Grotto.
Instead, she said the ministry’s geriatric department was involved, and sent details of a 2013 plan developed by the Myers-JDC-Brookdale Institute program to cope with the dementia epidemic, including promoting healthful lifestyles among the elderly. However, the plan does not suggest proactive screening of the middle-aged populations – a key component suggested by Kaufman – to find those at risk for dementia and taking steps to prevent brain atrophy from occurring.