Brain health and risk reduction: The GP’s role

‘It’s never too early and never too late’ for dementia risk reduction and dementia prevention, according to a 2020 report from the Lancet Commission.
 
This document synthesised the research of new reviews and meta-analysis to highlight the key modifiable risk factors for dementia, and when during a life course they most play a role.
 
The impact of this research should be wide reaching for policymakers around the world, but how do we translate it into our day-to-day practice?
 
Dementia is the leading cause of death for women in Australia and the second leading cause overall. Not only that, but it is the leading cause of disability for older Australians.
 
And while dementia’s pathology is often mixed, in Australia it’s mainly due to Alzheimer’s disease and vascular pathology, both of which start to occur in mid-life.
 
It therefore makes sense that if there are risk factors that can be targeted in early and mid-life to reduce risk, the opportunity is there for us as health professionals to make a real difference.
 
The 2020 Lancet Commission proposes 12 modifiable risk factors that account for 40% of the disease pathology. The remaining non-modifiable risk factors are a mixture of genetics, age, race/ethnicity and family history.
 
Although age is the commonest risk factor, dementia itself is not a normal part of ageing.
 
Life course risk reduction
The Lancet Commission highlights that many of the risk reduction strategies can be viewed over a life course. Not only that, but each can be thought of either enhancing cognitive reserve – essentially building a robust brain – or reducing pathophysiological change (reduction of amyloid deposits and neuro-fibrillary tangles).
 
The risk factors are based on world information and as such, some may be more relevant in low- and middle-income countries. However, for Australia where the population is diverse and still has several health inequities, it is probably just as relevant.
 
Early education
Education is key, so providing all school children with adequate primary and secondary education is important. This helps build resilient brains.
 
However, as a GP, what is our role in this? It might be advocacy, or it might be in detecting and supporting children who have learning needs, or disability that may impact on their capacity to learn.
 
It could be as simple as treating their glue ear to prevent hearing impairment, which is another risk factor for dementia.
 
Head injury
The impact of head injury, even if small and recurrent is significant.
 
There is already a widely known association between head injury and CTE, but it is likely that even small head injuries, particularly in younger people, are important to avoid. Educating families, and sports associations about the proper precautions for limiting head injury is vital.
 
Meanwhile, GPs need access to useful guidance on concussion protocols. It is also important to think more broadly about head injury in other groups, such as people in family and domestic violence situations.
 
Obesity/overweight
Education from a young age on the benefits of a healthy lifestyle in reducing the impact of chronic disease is highly relevant to dementia, as there is an association with mid-life obesity and dementia risk.
 
Linking this to exercise as a healthy lifestyle measure and the Mediterranean diet are two measures that are flagged in the WHO guidelines, both of which have moderate quality of evidence and a strong recommendation.
 
Smoking and alcohol
Both smoking and alcohol are linked to the development of dementia. The exact process by which they do this is not known, but it is possible that smoking acts via vascular mediated factors and alcohol is a known toxin for the brain.
 
As a GP it can be difficult to persuade people to stop smoking, or moderate their alcohol intake, but having a conversation around this in relation to supporting brain health in the future, may be the motivating factor for some.
 
Hearing loss
Protecting people from hearing loss, and early recognition of hearing loss is likely to be impactful in reducing risk of dementia. This risk factor was a new addition in the 2020 Lancet Commission report.
 
Further studies are needed, but early signs are that supporting people with hearing aids may be beneficial.

Dr Steph Daly believes Australian health professionals can make a real difference in helping people reduce their risk of dementia.
 
Hypertension
While it has been difficult to tease out the specific impact of hypertension on dementia, in mid-life this should be targeted with an aim of getting blood pressure below 130 mm Hg systolic.
 
The age suggested to target from is 40 years, which makes the 45–49 year health check an ideal MBS item number to utilise.
 
Air pollution
Later-life risk factors include some new faces, such as air pollution. Air pollution might not seem something we can target at a consultation level with the person in front of us, but we can advocate for climate change via RACGP Specific Interests, or by taking responsibility for our own impact on the environment.
 
Depression and social isolation
The importance of recognising that people can become depressed, and therefore have social isolation and loneliness and that this can increase risk of dementia, is important when considering a holistic assessment of the individual.
 
Depression is common in later life, as is social isolation, so addressing this in a consultation is important. Despite it being a late-life risk factor, it is probably worth noting that setting up good practices in early and mid-life probably reduce the risk of these developing in later life.
 
Diabetes
A late-life risk factor, although only probably here because it takes this long for the impact of diabetes to be seen in the brain. Managing and indeed preventing diabetes in the first place is probably a factor of mid and early life.
 
Brain health checks
Reducing stigma is an important aspect of dementia support. If people do not feel able to consult their practitioner due to the perceived stigma, further delay in diagnosis occurs. So, to tackle both the stigma and the risk factor management, a brain health check is ideal.
 
The Heart Foundation has successfully used heart health checks to raise public awareness of coronary heart disease, and dementia is just a small sideways step. In fact, heart health equals brain health for many of the risk factors above.
 
Brain health checks offer an opportunity to talk about the risk factors and tailor individual advice so people can make the change they want to. It also offers up the opportunity to educate patients that dementia is not normal ageing and highlight some of the symptoms that might raise concern.

There is now a risk reduction calculator that has been researched and is aimed at use in primary care. CogDrisk allows individuals to answer questions about their own lifestyle and age, takes 20 minutes to complete, and produces a summary of useful changes the individual can make to reduce their risk of dementia.
 
Brain health checks do not have their own item number, but many other item numbers can be used to offer brain health advice.
 
GPs can also include health assessments for 45–49-year-olds at risk of disease, and General Practice Management Plans for any disease that is a risk factor, eg hypertension, obesity, or diabetes.
 
Health assessments can also be conducted for Aboriginal and Torres Strait Islander people, who remain at greater risk, from a younger age of dementia, as well as for people with intellectual disability, which is another group at increased risk. 
 
Finally, in the over-75s health assessment, more should be made of a brain health check, rather than an opportunity to only perform a mini-mental state examination.
 
Log in below to join the conversation.

brain health dementia dementia risk modifiable risk factors World Alzheimer’s Month