Alzheimer’s disease (AD) affects approximately 6.2 million older Americans, roughly 11% of those aged 65 and above, and is the 6th leading cause of death in all American adults. Given that age is the primary risk factor for AD and the number of adults aged 65 and older will double to nearly 90 million by 2050, AD prevalence will continue to grow. AD affects not only the mental and economic wellbeing of family members but also the overall healthcare system. AD is a leading cost driver of Medicare and Medicaid services. At the existing rate of disease incidence, the current annual national spend of $305 billion is expected to skyrocket to $1 trillion by 2050.

Although AD has no known cure, recent evidence points to several advancements that may enhance the understanding of AD progression. Developments in neuroimaging, genetics, and clinical diagnosis have provided considerable evidence for the potential positive impact of preventative measures. For example, a growing body of evidence supports The Lancet Commission’s list of 12 potentially modifiable risk factors for dementia (e.g., physical inactivity, diet, hypertension). The potential for preventing or delaying dementia is an emerging field of research and further underscores the importance of brain health in midlife.

The Importance of Early Intervention and Prevention

Many questions remain regarding the treatment of AD, especially after the Food and Drug Administration’s conditional approval of novel drug aducanumab boosted hopes for a cure among patients. While aducanumab may help slow progression of AD among a select population, evidence around long-term impact and clinical understanding is lacking. The scientific community thus aligns on the importance of prevention and early diagnosis for AD, and providers remain interested in prevention as an efficient course of action.

Modifiable risk factors account for roughly 40% of dementia cases, opening the door for primary care providers to adopt early measures that can reduce preventable disease and lower the cost burden. Furthermore, missed diagnosis impacts about half of adults who would meet the diagnostic criteria for AD and other dementias. According to an Alzheimer’s Association study, improvements in early diagnosis could save $7.9 trillion from better management, planning, and care.

The most opportune time for AD risk reduction is during the midlife (i.e., ages 45–65), when the neuropathological changes related to AD initiate and risk factors take hold. While promoting brain health earlier in life can contribute to lower risk of brain impairment later in life, a lack of provider guidance to inform or screen midlife patients limits intervention. Additional barriers to promoting early brain health include a lack of consensus around the best cognitive assessments and insufficient evidence to support regular screening of at-risk patients. One way to equip healthcare professionals with the tools to address AD is to establish a better understanding of the disease and modes of prevention.

The Impact of Interconnected Lifestyle Factors and Preventing Cognitive Decline

In recognition of the challenges around early intervention and prevention, UsAgainstAlzheimer’s, in collaboration with Avalere Health, convened a working group comprising 8 experts with extensive experience developing and evaluating risk reduction and preventative measures for dementia. The group aligned on 6 recommendations to equip primary care providers with solutions to support brain health across a patient’s lifespan and to encourage the prevention of cognitive decline as early as midlife.

1. Neurovascular risk management: Given the strong association between cardiovascular risk factors and clinical outcomes in brain health, physicians should discuss brain health with hypertensive patients—especially those in their midlife—and inform patients of the risk of cognitive decline and how managing their hypertension can delay or prevent it.
2. Physical activity: Clinicians should assess patients for current physical activity level and ability. Since physical activity is associated with a reduced risk of cognitive decline, clinicians should establish a gradual, adaptable plan to reduce sedentarism among individuals not meeting physical activity recommendations.
3. Sleep: Clinicians should regularly assess patients’ sleep and establish an intervention for individuals experiencing insufficient or poor-quality sleep and refer patients suspected of having a sleep disorder to a specialist. Moderately strong evidence shows that disturbances or lack of sleep may negatively affect brain health, and investigational studies have found that sleep therapy intervention may improve brain health and ward off cognitive decline.
4. Nutrition: Clinicians should assess the quality of their patients’ diet. The Mediterranean diet, the DASH diet (Dietary Approaches to Stop Hypertension), and the MIND diet (Mediterranean and DASH Intervention for Neurodegenerative Delay) have all been associated with improved cognition and lowered risk of developing dementia in older adults.
5. Social activity: Clinicians should assess patients for social isolation and loneliness and suggest strategies for enhancing social activity for those who are identified as at risk for social isolation. Social isolation is associated with impaired physical and mental health, underlining the importance of positive social connection and social support as buffers against cognitive decline.
6. Cognitive stimulation: Clinicians should ask patients at each visit about their level of cognitive stimulation or activity (e.g., strategy games, reading) and suggest interventions for individuals with low levels of stimulation.

Initiatives to Support Brain Health Across the Lifespan

Calling attention to the rapid incline in AD prevalence and steadily increasing healthcare costs, a variety of organizations have established the following collection of initiatives, research studies, educational interventions, and community models to encourage prevention and early intervention through more holistic approaches to brain health:

• Us Against Alzheimer’s (UsA2): A prominent voice in AD advocacy, UsA2 aims to end AD by focusing on important elements of brain health, health equity, early detection and diagnosis, rapid treatment, and impacts on caregivers. The organization contributes considerably to mobilization, funding, and research, and it has created a toolkit for providers. Several UsA2 efforts serve to empower brain health across the lifespan and support health equity. The “Be Brain Powerful” campaign targets women’s brain health, and the “Brain Health Partnership” is a comprehensive strategy to include brain health as an element of overall good health and improve timely diagnosis by improving the existing ecosystem.
• Alzheimer’s Association: As a leading health organization focused on AD care, support, and research, the Alzheimer’s Association provides a wide range of services (e.g., care and support, education programs and provider tools, advocacy and awareness campaigns, community partnerships). The Alzheimer’s Association also supports research and clinical efforts around genomics and standardizing biomarker tests to improve early intervention. The Alzheimer’s Disease Neuroimaging Initiative aims to identify and standardize strategies for earlier diagnosis and disease monitoring.
• The Global Council on Brain Health (GCBH): American Association of Retired Persons, in collaboration with Age UK, established the council to provide trusted information on ways to maintain and improve brain health by making evidence-based recommendations. GCBH operates a hub-and-spoke model through which a group of global experts leads subsets of issue specialists who examine and report on specific priority prevention areas (e.g., physical exercise, diet, sleep).
• World Health Organization (WHO): The WHO guidelines on risk reduction of cognitive decline and dementia provide evidence-based recommendations on lifestyle behaviors and interventions to delay or prevent cognitive decline and dementia.

Avalere’s Capabilities

Avalere can support interested individuals or organizations to investigate solutions for improving brain health or other health conditions. Our past work has included developing shared decision-making tools, developing care pathways, educating providers, generating evidence on the health and economic value of counseling and education, and analyzing health disparities for health plans.

To learn more about how Avalere can support you in understanding the evolving evidence on Alzheimer’s disease and dementia connect with us.