Prevention research: a matter of patience  Does lifestyle change contribute to preventing dementia?

Living a healthy lifestyle reduces the risk of many diseases. That's what scientific research has shown us. But does it also lower the risk of dementia? ‘There are indications, but the evidence has not yet been unequivocally established.’ 

‘Prevention is a buzzword. We, here in academia, need to provide scientific evidence,’ says Edo Richard, Professor of Neurology, getting straight to the point. 'Of course, for many conditions, it has been scientifically proven that an unhealthy lifestyle increases the risk. Think, for example, of cardiovascular diseases. But in society, we sometimes draw connections that have not yet been demonstrated.' 

Dementia is a prime example of this, explains Richard. There are indeed many indications that an unhealthy lifestyle increases the risk of dementia, but the causal relationship has not been unequivocally established. 'We cannot say: if we remove those risk factors, then we also prevent dementia. Because simply put, we don't know that yet.' 

It does seem that factors such as high blood pressure, high cholesterol, obesity, smoking, and lack of exercise in middle age increase the risk of dementia in old age. But, says Richard, there is a significant time gap. 'Middle age is roughly between 50 and 70. It's only from 75 years old that the risk of dementia shoots up. A lot can change in those intervening years. For example, low blood pressure in old age seems to be associated with a higher risk of dementia.' 

Building with grains of sand 

This is confusing, and challenging. If you want to know if a change in lifestyle leads to a reduced risk of dementia, you first need to determine how to bring about that lifestyle change. And that's difficult enough, as we know from experience. Even if healthier living is achieved, do people actually develop less dementia ten or twenty years later? It's like building sandcastles, says Edo Richard. 'Each study contributes to our knowledge. Step by step, we hope to discover the relationship between lifestyle and dementia.' 

Together with PhD candidate Anne Roos van der Endt, Richard focuses on addressing the risk factors for dementia in a study setting. They particularly focus on people with a low socioeconomic status or migration background. Van der Endt says, 'It is known that these groups are at an increased risk of dementia and that they are difficult to reach with current prevention initiatives. A more personalized approach is needed.' 

A motivating coach 

This research, in collaboration with Maastricht University and funded by ZonMw, revolves around the MIND-PRO app. This app contains lifestyle advice, personal goals, and a lifestyle coach. This coach provides participants with tips and motivates them to work on their goals. The coach does not necessarily need a professional background in exercise or nutrition. 'Above all, someone needs to be motivational, to inspire the participants. If the coach has the same background, that also helps.' 

Participants have a personal conversation with their coach at the start, where they set personal goals together. Van der Endt explains, 'If a participant wants to exercise more, they set a goal, such as a certain number of steps or minutes of exercise per day. This is recorded in the app. The participant then receives advice via the app and can track their progress. The coach encourages them, via chat or video calls.' 

Anne Roos van der Endt investigates what the app, currently being developed by Interactive Studios, needs to fulfill. 'I interview people from the target group, show them the first version of the app, and try to understand their needs. Someone with a Surinamese-Hindustani background might benefit more from healthy recipes from the Hindustani cuisine than a mashed potato recipe. It's important that people eat what they like.' She also takes into account a possible language barrier, which can occur especially with first-generation migrants. 'That's why we also use a lot of videos and photos and ensure short and clear texts.' 

Overcoming the barrier 

The basis of this research lies in three previous studies in which Edo Richard was involved: the aforementioned grains of sand. In the first study involving 3500 seniors, half were offered lifestyle interventions, and the other half were not. Then, it was examined whether there was less dementia in the group with interventions. This turned out not to be the case. How is that possible? Richard says, 'Perhaps the group was too old, or the interventions were not intensive enough. But maybe it just doesn't work, of course.' 

In the subsequent study, 2700 seniors in Finland, France, and the Netherlands were given an eHealth platform for lifestyle change. 'We managed to get these over-65s to actively set goals. And they also had a very slight effect on blood pressure, obesity, and cholesterol. So, the idea works. But we haven't yet looked at whether this actually prevents diseases on a large scale.' 

The third study specifically targeted groups at high risk of dementia. An app focused on lifestyle change was developed for 1500 people in England with low incomes and people from the general population in China. Definitive results are not yet available, but these people seem to be using the app quite well, says Richard. 'It's very difficult to get people to participate in such lifestyle interventions. Many people don't want to, they have little confidence. Their distance from healthcare is enormous. But if people do participate, they actively engage. Once over that barrier, it is possible to actively work on their lifestyle with a coach.' 

Small effect, big consequences 

Edo Richard is optimistic but cautious about having too high expectations. 'The effect is probably small, not spectacular at the individual level. But if you zoom out to the entire population, you might be able to close a few nursing homes in twenty years because there is less dementia. This way, we can still have a major impact on overall public health.' 

But until we are sure, we must be honest about where we stand. Richard says, 'It is our task to safeguard trust in institutions and science. We can undermine that trust by making premature claims that we later have to qualify or retract. We must continue to take our role very seriously.' 

About dementia

Dementia is an umbrella term for various conditions in which the brain no longer processes information properly. The most well-known forms are Alzheimer's disease, in which proteins in the brain clump together, and vascular dementia, which involves damage to the brain's blood vessels. Generally, the condition is diagnosed by a general practitioner, neurologist, geriatrician, or specialist in elderly medicine through a conversation with the patient and caregiver. The doctor also administers a memory test, with questions such as 'what day is it'. Drawing a clock and remembering words are other tasks.

Ultimately, one in four people will develop a form of dementia; therefore, three out of four people will not. Dementia is not an automatic consequence of aging. To date, there is no treatment or cure available. A drug approved in the United States is currently under review by EMA, the European agency responsible for the approval of medicines. However, this drug has received much criticism due to its costs, limited effect on cognitive function, and high likelihood of side effects.

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