A charity perspective on
the dementia prevention
research agenda
Dr James Pickett
Head of Research
Alzheimer’s Society
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alzheimers.org.uk
What we mean by prevention?
• Primary prevention – the prevention of cognitive decline/ progression to
dementia in individuals with no clinical symptoms or detectable brain
changes.
RISK REDUCTION
•Secondary prevention – the prevention of cognitive decline/ progression to
dementia in individuals with no clinical symptoms but detectable preclinical
changes in the brain
EARLY DETECTION (SCREENING) & INTERVENTION
•Tertiary prevention – the prevention of further cognitive decline or burden
of disease in individuals with a diagnosis of dementia.
TIMELY DIAGNOSIS
SYMPTOMATIC TREATMENT
ENHANCING QUALITY OF LIFE FOR PEOPLE WITH DEMENTIA
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alzheimers.org.uk
Primary /
Secondary
/ Tertiary
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alzheimers.org.uk
Risk factors
www.alzheimers.org.uk/smartthinking
If you are over 40 (or have a history of dementia/cardiovascular problems in your family) you should get your
cholesterol levels checked regularly. Managing your cholesterol by eating a balanced diet that avoids
saturated fats will also help. Find out about managing cholesterol
If you are over 40 (or have a history of dementia/cardiovascular problems in your family) you should get regular
blood pressure checks to ensure it is at recommended levels. Find out about managing blood pressure
Avoid obesity and weight gain by eating healthily and taking exercise not only will this help reduce your risk of dementia but also your risk of heart disease and diabetes. Check if you are a
healthy weight for your height Adopt a balanced diet for life and incorporate regular exercise in the long term
stop smoking
Try and
- this will be of huge benefit to your health in a number of ways as well as reducing
your risk of dementia. Get advice on how to give up smoking
Overall, try and lead an active lifestyle that combines physical, social and
mental activity. Not only will it help to reduce your risk of dementia, you'll
hopefully enjoy life more as a result!
Where are we in research
•Epidemiological studies has established moderate risk factors – particularly
around understanding importance of vascular risk factors.
•Longitudinal prevalence studies have shown a reduction in incidence in
dementia over last 25 years (e.g. CFAS). Attributed to reduction in vascular
risk (stroke and CV disease).
•Need to understand more around the mechanisms of risk reduction in CV
factors? Reduction in vascular dementia, Alzheimer’s Disease or dementia?
•Less understanding of other non-CV risk factors.
Mental activity, education.
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alzheimers.org.uk
UK opportunities
•UK strength in epidemiology. Cohorts are reaching a maturity whereby
cognitive decline and dementia is relevant.
•Whitehall, 1946 cohort, Lothian 1921/36 cohort, CFAS, CFAS2
•Investment in new cohorts – for instance Biobank
•MRC dementias platform provides an infrastructure and strategy for
taking cohort epidemiology forward.
• There is a current lack of national public health ‘observatory’ for tracking
changes in dementia incidence. Current estimates of dementia incidence is
based on consensus agreed best estimates from studies >20 years ago.
•Knowledge from successful and unsuccessful behaviour change
interventions in other diseases.
•Cohesive, hollistic approach to risk prevention
•MRC National Prevention Research Initiative (NPRI)
•Change4life
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alzheimers.org.uk
Are primary prevention
studies realistic and feasible?
•
•
•
What intervention? Multifactoral
When in lifetime?
Duration and cost? (20+ years)
•
Can we identify high risk individuals?
• Genetics (ApoE4 homozygous OR 10)
• Family history (OR 1.4-2)
• Insulin resistance, obesity, BP
•Robust biomarkers that detect early changes? ‘proxy measures’
•Opportunities to follow up other intervention studies, for instance in
diabetes?
•How will this knowledge change the publics approach to managing
their cardiovascular risk?
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alzheimers.org.uk
Primary /
Secondary
/ Tertiary
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alzheimers.org.uk
Secondary prevention
– is it too late?
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alzheimers.org.uk
Where are we in research?
•Small studies using ‘proxy’ outcomes suggest that secondary prevention is
not ‘too late’ to delay or possibly prevent progression to dementia
•We are at a point where trials targeting individual or several risk factors at
needed to policy and ways forward.
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alzheimers.org.uk
Secondary prevention
Trial
Intervention
Funder
Location
FINGER (Finnish
Geriatric Intervention
Study to Prevent
Cognitive Impairment
and Disability)
multi-domain life-style for
people at high risk of
dementia (60-77 years)
National Institute for
Health and Welfare,
Finland
Finland
MAPT
Omega-3 Fatty Acids
and/or Multi-domain
Intervention in frail
elderly adults
Ministry of Health,
France
France
preDIVA (Prevention of
Dementia by Intensive
Vascular Care)
Nurse-led vascular
management of care for
elderly patients
Ministry of Public Health
Netherlands
HATICE (Healthy Aging
Through Internet
Counselling
in the Elderly)
Internet based approach
to CV management
EU
Finland, France,
Netherlands, Sweden,
UK
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alzheimers.org.uk
Secondary prevention
Trial
Intervention
Funder
Location
Exercise in MCI
12 month programme,
high intensity aerobic
exercise
NIA
USA
Preventing Cognitive
Decline in African
Americans with Mild
Cognitive Impairment
Exercise in African
Americans
NIA
USA
NIA
USA
Aerobic Exercise Training
in Mild Cognitive
Impairment Study
(AETMCI)
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alzheimers.org.uk
Secondary prevention
Trial
Intervention
Funder
Location
ScarletRoad
Anti-amyloid therapy in
Amyloid PET+
Roche
Global
BACe inhibitor in Amyloid
PET+
Merck
Global
DIAN (Dominantly
Inherited Alzheimer
Network)
DMT in presympomatic
familial families
Public-private
partnership, NIH,
Alzheimer’s Association,
Pharma
Global
API (Alzheimer’s
Prevention Initiative)
DMT in presympomatic
familial families
NIH, Genetech
Columbia
A4 trial (Anti-Amyloid
Treatment in
Asymptomatic AD Trial)
Anti-amyloid in amyloid
PET+ ApoE4+ carriers
NIH
USA
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alzheimers.org.uk
Secondary prevention
Trial
Intervention
Funder
Location
Brain training trial
Online cognitive training
for healthy older adults
Alzheimer’s Society
UK
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alzheimers.org.uk
UK opportunities
UK is not leading the way in intervention studies
• Current studies are long 5+ years and £10-25m
•UK is making a significant contribution to the identification of biomarkers
that enable ‘proxy’ measures in trials. Shorter duration/ cost.
•Need to use expertise from other areas of behaviour change research to
catch up.
•Current methodological considerations within current prevention studies.
•Addressing all social-economic groups, groups with lower levels of
education.
•Significant opportunities to have a role in EU Horizon 20:20 funding
•Working with memories services to evaluate support groups for patients identified
with early memory changes.
•Online programmes
•Peer to peer support programmes
•Coping with memory and prevention strategies
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alzheimers.org.uk
Population screening
Insufficient evidence to support screening of healthy individuals for early cognitive
impairment.
•
No robust validated sensitive and specific screening instruments
•
No recognised interventions to prevent cognitive decline
•
Identification and management of those at increased CV risk
•
Unknown impact
The Society does support the timely identification of people with early dementia
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alzheimers.org.uk
Developing UK policy
•
•
National Dementia Strategy that finishes in 2015.
Currently there is no draft new strategy.
• G8 commitments to 2025
• Doubling of research spending by government to ~£125m per
annum.
•
Do we need a separate strategy on healthy-brain ageing?
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Developing UK policy
Barrage of messages to the public = need for strong, clear advice
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Conclusions
More research
• Focus on CV factors, more focus on novel non-CV factors.
• Methodological issues;
• Better, quicker outcome measures.
• Study demographics.
• High co-morbidity
• Need to understand the strength of potential interventions
• Better support for individuals with earlier stages of cognitive
impairment
Policy
• Need new National Dementia Strategy
• Greater recognition of public health within strategy
• Lifelong course approach to mental health
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alzheimers.org.uk
Thank you
Dr James Pickett
[email protected]
Head of Research
Alzheimer’s Society
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alzheimers.org.uk