International overhaul of dementia guidelines unveiled

GPs now have a new set of on-the-ground guidelines to help them prevent Australia’s leading cause of death: dementia.
 
The importance of lowering dementia risk across the life course has been highlighted by the World Health Organization (WHO) in its first guideline update in seven years.
 
Its new prevention advice focuses on proven actions that can effectively lower dementia risk ‘through early awareness and timely action’, pulling together evidence that can be actioned at a primary care level as well as broader health system initiatives.
 
Amongst the recommendations are behaviour and lifestyle interventions to reduce the risk of dementia, including daily cognitive stimulation and training, and social activities for people who have normal cognition or are experiencing mild cognitive impairment.

Updated advice also includes interventions that reduce risk of noncommunicable diseases, including increasing physical activity, stopping smoking, reducing alcohol consumption, adopting a healthy diet, and a new recommendation to reduce exposure to air pollution.
 
Management of cardiometabolic conditions, such as hypertension, diabetes, and high cholesterol can also help reduce dementia risk and there is emphasis on the benefits of tailored ‘multidomain’ interventions which target three or more risk factors. 
 
There is also updated advice on the use of supplements, with the guidelines stating that to reduce the risk of cognitive decline and/or dementia specifically, ‘supplementation of vitamins B and E, omega-3 polyunsaturated fatty acids (PUFA) and multivitamins/minerals is not recommended.’
 
‘That’s important for GPs to know because patients do come to see us asking about various supplements,’ said Dr Stephanie Daly, Chair of RACGP Specific Interests Dementia.
 
‘There’s a lot of people in the private market wanting to influence people as to what they should be doing to look after their health.’
 
There are also updated recommendations on the role of hormone replacement therapy in the context of dementia.
 
‘Menopausal hormone therapy is not recommended for specifically reducing the risk of cognitive decline and/or dementia in postmenopausal women aged 65 years and older,’ the guidelines state.
 
‘For women aged below 65 years – including those experiencing premature ovarian insufficiency, early menopause or perimenopause – and for the specific purpose of reducing the risk of cognitive decline and/or dementia, there is currently insufficient evidence to advise for or against the use of menopausal hormone therapy.’
 
The WHO says its new guidelines are designed to promote a ‘life-course understanding of dementia risk’, recognising that exposure to risk factors accumulates over time and that certain risk factors may have a greater impact at specific life stages.
 
But up to 45% of the dementia risk can be attributed to modifiable factors, such as smoking, social isolation, physical inactivity, air pollution and noncommunicable diseases, including high blood pressure and diabetes, the WHO explains.
 
Dr Daly says this helps to emphasise the message that brain health is something ‘we should all be across and talking to our patients about’.
 
‘Although it’s a disease that affects older people primarily, action that can be taken to reduce the risk is much earlier than we’ve been talking to people about,’ she told newsGP.
 
‘As primary care practitioners, we need to think about brain health as really a life course intervention, and that there’s a lot we can do from early life – maybe even before midlife.
 
‘We need to really advocate for thinking about brain health as a critical conversation that every GP needs to understand, like we all know how to have cardiovascular health conversations.
 
‘I’m not sure that everybody is up to speed with the concept of brain health and how to have those conversations so I’m hoping that these guidelines, together with the [upcoming Monash University] clinical guidelines, will help really emphasise that message that brain health is really something we should all be across and talking to our patients about.’
 
As Australia’s only researcher on the WHO’s Guideline Development Group that produced the new advice, Professor Kaarin Anstey, Director of the UNSW Ageing Futures Institute, said these guidelines are a vital step forward.
 
The role of GPs in helping to action these updated guidelines is ‘extremely important’, she told newsGP.
 
‘The guidelines are aimed at GPs who are most important for providing clinical advice and support with managing these risk factors at the individual level. They also are directed to other clinicians, as well as policy makers,’ Professor Anstey said.
 
Of interest are recommendations on diet, exercise and cognitive engagement.
 
‘Evidence on health behaviours relating to exercise, healthy diet, cognitive activity is now strong enough to make recommendations about these to patients,’ she said.
 
‘There is now sufficient evidence to make recommendations to undertake cognitive activity and interventions to address hearing loss. Evidence to continue with management of hypertension, dyslipidaemia, and diabetes (this is not new).
 
‘There is a new recommendation that dietary restriction may be offered to adults who are overweight and obese to reduce risk of cognitive decline, a new recommendation on multidomain interventions i.e. addressing risk factors holistically. These usually include physical activity, healthy dietary pattern and cognitive stimulation or training.
 
‘And a new recommendation to reduce exposure to air pollution. It should be noted that the evidence base is still growing and several recommendations are of low certainty. This is especially where evidence was mostly drawn from observational studies.’
 
But Dr Daly said governments must now support GPs to provide longer consultations to better action this advice.
 
‘You can’t do this work in a short consult, whether you’re doing risk reduction or interventions to actually pick up cognitive decline,’ she said.
 
‘We need to have better funded, longer consults in order to do this because these are complex conversations that require a detailed conversation and it’s not something that fits into short time framed medicine.’
 
Professor Anstey added that societal factors also influence risk factors and access to healthcare.
 
‘Dementia risk reduction is clearly complex and involves many aspects of health over the life course. This requires a whole of society approach,’ she said.
 
‘We need to ensure people can afford access to GPs to help manage risk factors, but also access to affordable healthy food, opportunities to exercise, and have clean air, hearing aids and social activities.’
 
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