IPA Bulletin: VOLUME 36, NO. 2 • JUNE 2019
Mary Sano, IPA President
As a neuropsychologist, who has spent most of my life working in dementia and cognitive impairment in the elderly, I am pleased that there is growing attention to this topic. This is tempered by the fact that these past few months have seen several reports of negative results on some of the most high profile approaches to treating Alzheimer’s disease (AD). Specifically, in March, Biogen and Eisai announced they would terminate all currently ongoing aducanumab trials, because an interim analysis indicated “futility” for the two major ongoing trials, EMERGE and ENGAGE. That is these studies would not find a beneficial effect of their primary endpoint. This failure has been a blow to much of the drug development field because this agent very effectively removed amyloid from the brains of patients with AD and it was hoped that a clinical benefit would result. Several other molecules that were in clinical trials and modify different aspects of amyloid accumulation in the brain have also failed, and some may even worsen cognitive function. While there are other targets and there is enthusiasm for starting earlier to prevent cognitive loss in those with amyloid, there is some skepticism and even concern about these highly technical and very costly approaches to preventing dementia.
Perhaps that is why I have been so fascinated by the interest in dementia prevention. The recent release of the WHO Guidelines on Risk Reduction of Cognitive Decline and Dementia is one example of a systematic look at approaches to reducing risk. The challenge of writing guidelines for global communities is great, and while the task of summarizing evidence is huge, one is also struck by the lack of information for a breadth of populations. For example is the recommendation for someone at 60 years of age the same as for someone at 80; Do recommendations get tailored to your past health history; Does region and climate change the benefit of an intervention? Does physical activity have a benefit in a place where air quality is low or climate is tropical? This complexity was realized in the WHO report which resulted in only two “strong” recommendations for reducing cognitive decline among the twelve areas described in the Executive Summary. Of note, these two areas had only low (tobacco cessation) or moderate (physical activity) quality of evidence. In the case of tobacco cessation, the recommendation is further modified by adding it may have other health benefits. Among dietary interventions, the Mediterranean-like diet was only conditionally recommended. An unusual occurrence was the “strong recommendation” to “Not recommend” specific supplements (vitamin B and E) polyunsaturated fatty acids and complex supplements. This maybe a bit confusing and it will be important to observe the impact and uptake of this recommendation.
Reduction of several other risks that were evaluated and received “conditional” status or no recommendation for reducing and risk of cognitive decline and dementia. For example, social activity interventions, management of depression, and management of hearing loss, receive no recommendations for reducing cognitive decline and dementia. In many cases this is due to limited data, and in some cases (hearing loss, and management of depression) previously published guidelines exist to recommend the intervention for other health reasons. This report reminded me that we can never forget the whole person, especially in old age. While some specific interventions may not currently have evidence to support a direct effect on cognition, they may be relevant to a wider range of issues that address “Better Mental Health for Older Persons”.
Finally, I want to share with you my observation that both strong and conditional recommendations require modifying behavior to improve health outcomes. Behavioral health has long been part of the mental health field. However, the specific and specialized field of behavioral health in aging is upon us. The next decades will see people living longer and we at IPA want to help collect the evidence base to tell them how to live better. Studies to learn the best methods to motivate aging populations are in desperate need. Using technology in age-friendly ways to improve compliance, to track progress on new habits and to receive support to persevere in healthy activities are all worthy of study. I hope this mission will mean as much to you as it does to me.