BACKGROUNDThe potential economic value of interventions to prevent late-onset dementia is unknown. We modelled this for potentially modifiable risk factors for dementia. METHODSFor this modelling ...study, we searched PubMed and Web of Science from inception to March 12, 2020, and included interventions that: successfully targeted any of nine prespecified potentially modifiable risk factors (hypertension, diabetes, hearing loss, obesity, physical inactivity, social isolation, depression, cigarette smoking, and less childhood education); had robust evidence that the intervention improved risk or risk behaviour; and are feasible to enact in an adult population. We established when in the life course each intervention would be delivered. We calculated dementia incidence reduction from annual incidence of dementia in people with each risk factor, and population attributable fraction for each risk, corrected for risk factor clustering, and how effectively the intervention controls the risk factor. We calculated the discounted value of lifetime health gain and effect on cost (including NHS, social care and carer costs) per person eligible for treatment. We estimated annual total expenditure on the fully operational intervention programme in England. FINDINGSWe found effective interventions for hypertension, smoking cessation, diabetes prevention, and hearing loss. Treatments for stopping smoking and provision of hearing aids reduced cost. Treatment of hypertension was cost-effective by reference to standard UK thresholds. The three interventions when fully implemented would save £1·863 billion annually in England, reduce dementia prevalence by 8·5%, and produce quality-adjusted life-year gains. The intervention for diabetes was unlikely to be cost-effective in terms of effect on dementia alone. INTERPRETATIONThere is a strong case for implementing the three effective interventions on grounds of cost-effectiveness and quality-of-life gains, as well as for improvements in general health. The interventions have the potential to remain cost-saving or cost-effective even with variations in dementia incidence and costs and effectiveness of interventions. FUNDINGEconomic and Social Research Council.
Abstract
Given considerable variation in diagnostic and therapeutic practice, there is a need for national guidance on the use of neuroimaging, fluid biomarkers, cognitive testing, follow-up and ...diagnostic terminology in mild cognitive impairment (MCI). MCI is a heterogenous clinical syndrome reflecting a change in cognitive function and deficits on neuropsychological testing but relatively intact activities of daily living. MCI is a risk state for further cognitive and functional decline with 5–15% of people developing dementia per year. However, ~50% remain stable at 5 years and in a minority, symptoms resolve over time. There is considerable debate about whether MCI is a useful clinical diagnosis, or whether the use of the term prevents proper inquiry (by history, examination and investigations) into underlying causes of cognitive symptoms, which can include prodromal neurodegenerative disease, other physical or psychiatric illness, or combinations thereof. Cognitive testing, neuroimaging and fluid biomarkers can improve the sensitivity and specificity of aetiological diagnosis, with growing evidence that these may also help guide prognosis. Diagnostic criteria allow for a diagnosis of Alzheimer’s disease to be made where MCI is accompanied by appropriate biomarker changes, but in practice, such biomarkers are not available in routine clinical practice in the UK. This would change if disease-modifying therapies became available and required a definitive diagnosis but would present major challenges to the National Health Service and similar health systems. Significantly increased investment would be required in training, infrastructure and provision of fluid biomarkers and neuroimaging. Statistical techniques combining markers may provide greater sensitivity and specificity than any single disease marker but their practical usefulness will depend on large-scale studies to ensure ecological validity and that multiple measures, e.g. both cognitive tests and biomarkers, are widely available for clinical use. To perform such large studies, we must increase research participation amongst those with MCI.
Action on the same behavioural and intermediate risk factors for NCDs (including tobacco, poor diet, physical inactivity, and alcohol) and consequent reductions in raised blood pressure, blood ...cholesterol, obesity, and diabetes could prevent between 3% and 20% of predicted new cases of dementia in 20 years.3,4 These gains are likely to be greater if combined with action to protect brain health throughout life--including addressing alcohol and substance abuse and head injuries in adolescents and young people; supporting lifelong learning and improved workplace health in middle life; and improving social interactions, stimulation, and supportive care in later life.
Purpose
– The purpose of this paper is to outline the action that can be taken to ensure longer and healthier lives.
Design/methodology/approach
– The paper draws on the relevant recommendations set ...out by the National Institute for Clinical Excellence to delay or prevent the onset of ill health in later years, followed by a number of recommended approaches to promote healthy behaviours in older adults as well as those in midlife.
Findings
– There is a clear need for public health and the prevention agenda to help ensure that later years are not just longer, but healthier.
Practical implications
– The paper identifies how, when and where the health risks associated with the majority of years lost to ill health can be addressed, and advocates the importance of taking an asset-based approach to promoting good health in older people.
Originality/value
– The paper is a comprehensive review of the key public health actions that can be taken to ensure longer and healthier lives.
This Review, in addressing the unacceptably high mortality of patients with liver disease admitted to acute hospitals, reinforces the need for integrated clinical services. The masterplan described ...is based on regional, geographically sited liver centres, each linked to four to six surrounding district general hospitals—a pattern of care similar to that successfully introduced for stroke services. The plan includes the establishment of a lead and deputy lead clinician in each acute hospital, preferably a hepatologist or gastroenterologist with a special interest in liver disease, who will have prime responsibility for organising the care of admitted patients with liver disease on a 24/7 basis. Essential for the plan is greater access to intensive care units and high-dependency units, in line with the reconfiguration of emergency care due to the COVID-19 pandemic. This Review strongly recommends full implementation of alcohol care teams in hospitals and improved working links with acute medical services. We also endorse recommendations from paediatric liver services to improve overall survival figures by diagnosing biliary atresia earlier based on stool colour charts and better caring for patients with impaired cognitive ability and developmental mental health problems. Pilot studies of earlier diagnosis have shown encouraging progress, with 5–6% of previously undiagnosed cases of severe fibrosis or cirrhosis identified through use of a portable FibroScan in primary care. Similar approaches to the detection of early asymptomatic disease are described in accounts from the devolved nations, and the potential of digital technology in improving the value of clinical consultation and screening programmes in primary care is highlighted. The striking contribution of comorbidities, particularly obesity and diabetes (with excess alcohol consumption known to be a major factor in obesity), to mortality in COVID-19 reinforces the need for fiscal and other long delayed regulatory measures to reduce the prevalence of obesity. These measures include the food sugar levy and the introduction of the minimum unit price policy to reduce alcohol consumption. Improving public health, this Review emphasises, will not only mitigate the severity of further waves of COVID-19, but is crucial to reducing the unacceptable burden from liver disease in the UK.
Brain health is essential for physical and mental health, social well‐being, productivity, and creativity. Current neurological research focuses mainly on treating a diseased brain and preventing ...further deterioration rather than on developing and maintaining brain health. The pandemic has forced a shift toward virtual working environments that accelerated opportunities for transdisciplinary collaboration for fostering brain health among neurologists, psychiatrists, psychologists, neuro and socio‐behavioral scientists, scholars in arts and humanities, policymakers, and citizens. This could shed light on the interconnectedness of physical, mental, environmental, and socioeconomic determinants of brain disease and health. We advocate making brain health the top priority worldwide, developing common measures and definitions to enhance research and policy, and finding the cause of the decline of incidence of stroke and dementia in some countries and then applying comprehensive customized cost‐effective prevention solutions in actionable implementation units. Life cycle brain health offers the best single individual, communal, and global investment.
With population ageing worldwide, dementia poses one of the greatest global challenges for health and social care in the 21st century. In 2019, around 55 million people were affected by dementia, ...with the majority living in low- and middle-income countries. Dementia leads to increased costs for governments, communities, families and individuals. Dementia is overwhelming for the family and caregivers of the person with dementia, who are the cornerstone of care and support systems throughout the world. To assist countries in addressing the global burden of dementia, the World Health Organisation (WHO) developed the Global Action Plan on the Public Health Response to Dementia 2017-2025. It proposes actions to be taken by governments, civil society, and other global and regional partners across seven action areas, one of which is dementia risk reduction. This paper is based on WHO Guidelines on risk reduction of cognitive decline and dementia and presents recommendations on evidence-based, multisectoral interventions for reducing dementia risks, considerations for their implementation and policy actions. These global evidence-informed recommendations were developed by WHO, following a rigorous guideline development methodology and involved a panel of academicians and clinicians with multidisciplinary expertise and representing geographical diversity. The recommendations are considered under three broad headings: lifestyle and behaviour interventions, interventions for physical health conditions and specific interventions. By supporting health and social care professionals, particularly by improving their capacity to provide gender and culturally appropriate interventions to the general population, the risk of developing dementia can be potentially reduced, or its progression delayed.
Background
The potential economic value of interventions to prevent dementia is unknown. We modelled this for potentially modifiable dementia risk factors.
Method
We searched PubMed and Web of ...Science from inception to July 2018 and included interventions that (a) successfully targeted any of nine pre‐specified potentially modifiable risk factors (hypertension, diabetes, hearing loss, obesity, physical inactivity, social isolation, depression, cigarette smoking and less childhood education), (b) had robust evidence that the intervention improved risk or risk behaviour and (c) are feasible in an adult population. We established when in the life‐course each intervention would be delivered. We calculated dementia incidence reduction from: annual incidence of dementia in people with each risk factor; population attributable fraction for each risk, corrected for risk factor clustering, and how effectively the intervention controls the risk factor. We calculated the discounted value of lifetime health gain (including reduced dementia mortality) and impact on cost (including NHS, social care and carer costs) per person eligible for treatment. We estimated annual total expenditure on the fully operational intervention programme in England.
Result
We found effective treatments for hypertension, stopping smoking, diabetes prevention and hearing loss. Treatments for stopping smoking and provision of hearing aids reduced cost. Treatment of hypertension was cost‐effective by reference to standard UK thresholds. The three interventions when fully implemented would save £1·863 billion annually in England, reduce dementia prevalence by 8·5% and produce QALY gains. The intervention for diabetes was unlikely to be cost‐effective in terms of impact on dementia alone.
Conclusion
There is a strong case for implementing the three effective interventions on grounds of cost‐effectiveness and quality of life gains, as well as for improvements in general health. While some people will decline or discontinue interventions, there is considerable room for the interventions to remain cost‐saving or cost‐effective even if adherence is lower.
Abstract
Background
The potential economic value of interventions to prevent dementia is unknown. We modelled this for potentially modifiable dementia risk factors.
Method
We searched PubMed and Web ...of Science from inception to July 2018 and included interventions that (a) successfully targeted any of nine pre‐specified potentially modifiable risk factors (hypertension, diabetes, hearing loss, obesity, physical inactivity, social isolation, depression, cigarette smoking and less childhood education), (b) had robust evidence that the intervention improved risk or risk behaviour and (c) are feasible in an adult population. We established when in the life‐course each intervention would be delivered. We calculated dementia incidence reduction from: annual incidence of dementia in people with each risk factor; population attributable fraction for each risk, corrected for risk factor clustering, and how effectively the intervention controls the risk factor. We calculated the discounted value of lifetime health gain (including reduced dementia mortality) and impact on cost (including NHS, social care and carer costs) per person eligible for treatment. We estimated annual total expenditure on the fully operational intervention programme in England.
Result
We found effective treatments for hypertension, stopping smoking, diabetes prevention and hearing loss. Treatments for stopping smoking and provision of hearing aids reduced cost. Treatment of hypertension was cost‐effective by reference to standard UK thresholds. The three interventions when fully implemented would save £1·863 billion annually in England, reduce dementia prevalence by 8·5% and produce QALY gains. The intervention for diabetes was unlikely to be cost‐effective in terms of impact on dementia alone.
Conclusion
There is a strong case for implementing the three effective interventions on grounds of cost‐effectiveness and quality of life gains, as well as for improvements in general health. While some people will decline or discontinue interventions, there is considerable room for the interventions to remain cost‐saving or cost‐effective even if adherence is lower.
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