Alzheimer’s Disease as a case study

For many diseases, medical treatment alone is not enough. A key factor for preventing or slowing the progression of a disease must involve lifestyle changes. Truly improving patient outcomes can only be done by pairing treatments with such health and wellness changes. In this piece, Dr. Matthias Berkes talks about the research behind how we can start helping people incorporate lifestyle and wellness changes into their health plan, and he uses Alzheimer's Disease as an example to illustrate the solutions we can employ.

I want to do a quick exercise. I want you to think of at least two, maybe three, individuals in your life that are above the age of 65. Have them in mind? Their personalities, hobbies, maybe specialty baked goods? You are probably thinking of loved ones, and depending on your age, they may be grandparents, parents, or possibly siblings. Maybe a mentor or a spouse. Alongside their most salient traits — their laughs, their quirks, that twinkle in their eyes — they probably also have concerns related to their health. And unfortunately, odds are fairly high that at least one of the individuals you’ve thought of has received, or is likely to receive, a diagnosis of dementia. Even just reading that term may have instinctively made you shift focus to another individual in your life affected by it.

Alzheimer’s disease (AD) is the most common cause of dementia, accounting for ~60-80% of all dementia cases (other causes involve vascular issues or as a result of traumatic brain injury, for example). As such, when we hear someone talk about dementia, there’s a good chance they’re speaking about AD. Symptoms of dementia include issues with memory loss, planning difficulties, language impairment, and often also include behavioral changes and difficulty in performing everyday tasks.

So the symptoms don’t sound great — and they’re not. But should we be concerned? Alzheimer’s is ultimately a disease of aging where an individual’s risk of developing AD doubles every 5 years after the age of 65. Here in Canada, in 2021 there were ~7 million individuals over the age of 65 with a prevalence of dementia of ~7% (or about 450k affected individuals). Worldwide, approximately 55 million individuals are affected, with that number expected to rise to 78 million by 2030. Societally, the global cost of dementia was approximated at ~$1.9 trillion(!) in 2019. Pharmaceutical treatments vary in their effectiveness in treating the symptoms of AD with no guaranteed cure at present. Every diagnosis of dementia includes enormous emotional, social, and physical costs for the affected individual and their loved ones.

HOW CAN WE IMPROVE PATIENT OUTCOMES?

This sounds like a lot of doom and gloom, but there is one potential ray of light. In the current absence of a pharmaceutical cure for AD, the key to handling dementia may lie in preventing or delaying symptoms. We can’t do anything about risk factors like age and genetics, but individuals can take control over lifestyle factors that have been shown to prevent or delay dementia symptoms and onset. What do we mean when we discuss ‘lifestyle factors’? Simply put, these are any lifestyle choices and activities that have positive benefits for healthy cognitive aging. Factors like engaging in effortful physical activity, maintaining a balanced and healthy diet, and even speaking two languages (i.e., bilingualism) have all been shown to delay the onset of symptoms and improve cognitive outcomes in dementia.

For example, one meta-analysis found that physical activity was associated with an 18% reduction in the risk of developing dementia. Another study found that aerobic exercise led to significantly improved cognitive scores for dementia patients compared to sedentary peers. Strict adherence to diets that target cardiovascular improvement have also shown evidence for reduced incidence of AD. When it comes to language and culture, bilinguals show symptoms of dementia 4 years later than monolinguals — a remarkable result that has been shown not only in Canada but globally as well. Even when comparing the brain health of bilinguals to monolinguals in older age, bilinguals have better cognitive and clinical outcomes at similar levels of neuropathology. When we consider everything together, a pattern becomes clear: lifestyle changes are the best way to prevent and delay the development of dementia.

THE BARRIERS TO ADOPTING LIFESTYLE CHANGES

But how do we make these changes, and when? What’s preventing physicians from recommending these lifestyles to their patients? Why aren’t we, as individuals, adopting these beneficial habits and skills on our own? As with any behavior, change is hard! Further complicating the issue is that these lifestyle changes must occur well before a diagnosis of dementia — we’re talking years, maybe decades, in advance. There are a multitude of reasons why patients might not adhere to a new recommended lifestyle, and they include (but are not limited to) the following:

1. Optimism bias: The optimism bias refers to our tendency to overestimate how frequently, or how likely, positive outcomes will occur in our life. A healthy middle-aged adult may feel like dementia is an illness that would never affect them. This ties into another bias called the ‘ostrich effect’, where we prefer to avoid negative information (or bury our heads in the sand), including that which might aid us in our behaviors and goals. The same adult may have a family history of dementia, but they believe their current health is no reason to worry and they’d rather not think about that eventual outcome.
2. Present bias: Because AD is ultimately a disease of aging, there is a very real lack of salience for anyone in their younger or middle years of life. The outcome you are trying to prevent is so far in the future that it has no impact on your current life trying to juggle a career, family, and social life.
3. Poor understanding of future consequences: Along with the previous point (i.e., there is a lack of salience) is the possibility that patients may also lack understanding how lifestyle changes can affect future outcomes. It is easy for a physician to recommend a new exercise routine or to take up a foreign language class, but if the patient cannot understand how this relates to a possible illness in 5, 10, or 20 years, then the advice is unlikely to be followed.
4. Forgetfulness: We understand — life is hectic. Between work, picking your daughter up from school, and cooking dinner, you forgot to get that half hour of French learning in. A failure to adhere to a new routine may not come from any specific cognitive bias, but simply from forgetfulness. For example, one study examining medication uptake in diabetic patients found that almost 50% of patients mentioned forgetfulness as the reason for non-intentional nonadherence.

POTENTIAL SOLUTIONS TO OVERCOME BARRIERS

These are just a few of the barriers that get in the way of developing healthy lifestyles that can prevent dementia further down the line. Once a physician recognizes that a patient may need to adjust their current lifestyles for future benefit, some of the following are ways to help patients adopt a new routine:

1. Provide patients with information and education: Possibly of greatest importance is the need for proper physician-patient education. The goal of educational efforts is to improve patient knowledge about risk factors, consequences, and preventative measures. In the case of dementia, this would involve discussing with patients how a family history of dementia, poor diet, or a sedentary lifestyle are all contributors to increased risk and should be addressed before dementia occurs. A strong education in healthy behaviours and their benefits is the foundation upon which further behavioural interventions can be layered.
2. Highlight near-term benefits: Depending on how a physician’s recommendation is framed, patients may have better or worse adherence to a new lifestyle. In general, framing options from the perspective of positive gain rather than negative will be viewed more favorably. For example, framing the suggestion to learn a new language as “gaining a new skill and access to culture” and avoiding negatives such as a “loss of free time” or “difficult”. Because the immediate benefits of new lifestyles (e.g., new skill or greater levels of energy) are apparent over future benefits (i.e., delaying dementia), hyperbolic discounting — favoring smaller immediate gains over greater future gains — could work in a physician’s favor when discussing these lifestyles with a patient.
3. Visualize a future version of yourself: Immediate, short-term goals are useful to motivate action in the present, but there is also evidence to suggest that a focus on future outcomes can spur positive behaviour. In one study, individuals that could interact with a realistic computer rendering of their “future self” (i.e., an aged visualization of themselves) increased financial savings behaviours over those individuals who did not interact with an aged rendering. Although this study examined financial behaviours, the same principle applies to healthy living. Helping a patient focus on who they want to be in the future can lead to behaviours that, just as with finances, act as small deposits that add up into future savings.
4. Enable physician-patient joint planning: Enacting lifestyle changes in patients needs to be a collaborative effort between physician and patient. There is some evidence that directing patients to a specific treatment lowers patient satisfaction, so when possible, the ideal scenario is to not make direct recommendations but rather to guide patients to an option that they find enjoyable and doable. Some recent research that examined the effects of older adults using either a brain training app or a language learning app to boost cognitive performance found that both training methods improved performance compared to a control group, but enjoyment and subsequent adherence was higher for the group learning a second language.
5. Create habits through reminders and routine: Consistency is key for long-term habit formation. Considering that forgetfulness is one of the greatest barriers, establishing ways to circumvent this issue is essential. One of the most straightforward ways to do this is by nudging patients to exercise, buy healthier food, etc., through reminders. This could be done through periodic text messages sent to a patient’s phone, quick follow-up phone calls, or reminders sent through learning apps on a smartphone or tablet. There are advantages and disadvantages to each method, so deciding how to proceed should entail a conversation between patient and provider for the best outcome.

CONCLUSION

Ultimately, the goal of any recommended lifestyle change is for the health and wellbeing of the patient: delaying or preventing the effects of dementia in older age and improving the quality of life and enjoyment for the patient in the interim. Considering that a delay of 5 years of AD onset leads to an ~50% decrease in the prevalence of the disease, delaying the development of symptoms through lifestyle interventions is one of the best individual, and therefore societal, changes we can make.