Rohwedder S, Hudomiet P, Hurd MD. Individuals' interest in cognitive screening, dementia diagnosis, and treatment: New estimates from a population-representative sample. Rand Corporation, December 3, 2024 Rand Corporation
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These interesting studies end with excellent recommendations. There is much that individuals can do to decrease the chance of dementia, and this is a cause for optimism and hope. There are also policy changes that can make a difference. This report is U.S. centered, so some findings will not apply to many other countries with universal health care. The team analyzed data from the U.S. Health and Retirement Study (HRS) of 20,000 older adults who have been participating since 1992, to detect who is at elevated risk for dementia. In line with other studies—as summarized and analyzed in our Lancet commission on dementia—they found that previous cognitive reserve (high cognition) was protective, as was ever having worked, which builds cognitive, social, and financial resources (Livingston et al., 2024). In contrast, not having private health insurance, illnesses, and lifestyle factors such as functional restriction, diabetes, obesity, excessive alcohol, and lack of exercise were important risks. Functional ability restriction, which is a nonspecific result in many illnesses, also leads to restrictions in ability to exercise, socialize, and self-care and is often associated with depression. No private health insurance reflects lack of money, and likely relates to overall poor health. Participants also talked about the costs of health care in terms of testing and then receiving a diagnosis.
The authors discuss low screening rates for dementia: In the U.S. 16 percent of people aged 65 and older participate in cognitive assessment during a routine visit. There is, however, no evidence that screening is useful in terms of better treatment or outcome. It might be better for people to have a cognitive assessment if they or their families notice a cognitive deterioration.
They find that receiving a diagnosis leads to useful actions. This is not just thinking of the existing disease modifying treatments (DMT), which have a small effect, high cost, and some side effects but are a big move forward. As this study identifies, there are many other strategies that can be helpful, such as considering wills and who can help and eventually make decisions, as in powers of attorney. Maximizing physical health and getting assistance in everyday life so people can manage their medications and continue to eat well can make a huge difference. Assessing and mitigating risks, such self-neglect, driving, or cooking, and having supporting carers can make a big difference. There are other medications besides DMTs that are cheaper with fewer side effects that can also be helpful. More than half of the survey respondents (60 percent) would take a DMT if it would give them three more years of independent living. It surprises me that it is so low. But we have no evidence that this will happen since the current DMT studies only last 18 months and it is unclear if there is a wider separation between treatment and control groups after a year, i.e., that the illness is truly modified. DMTs may change. We all hope that not only we can find more effective drugs, but that the current drugs may become cheaper and less burdensome, for example, by not requiring intravenous administration.
References:
Livingston G, Huntley J, Liu KY, Costafreda SG, Selbæk G, Alladi S, Ames D, Banerjee S, Burns A, Brayne C, Fox NC, Ferri CP, Gitlin LN, Howard R, Kales HC, Kivimäki M, Larson EB, Nakasujja N, Rockwood K, Samus Q, Shirai K, Singh-Manoux A, Schneider LS, Walsh S, Yao Y, Sommerlad A, Mukadam N. Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission. Lancet. 2024 Aug 10;404(10452):572-628. Epub 2024 Jul 31 PubMed.
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