Memory loss, behavioral changes, cognitive deficits: the Alzheimer’s disease it involves a dramatic loss of autonomy for those affected and has a heavy impact on health care costs. Its prevention has become a real social challenge.
These guidelines are detailed in an article published on The Lancet Regional Health—Europe .
Prevention of Alzheimer’s disease: some details on the guidelines
With 10 million people affected in Europe, Alzheimer’s disease is the most common neurodegenerative disease. It is characterized by progressive disabling memory loss and cognitive deficits caused by a buildup of toxic proteins in the brain. Its social and economic impact is considerable. On a global scale, it is estimated to be worth about 1.5 trillion dollars a year and in Switzerland 11.8 billion francs a year.
Improved lifestyles (physical activity, attention to nutrition, cardiovascular prevention) have reduced the risk of developing Alzheimer’s disease or related forms. However, the prevalence of dementia continues to increase as the population ages. Today, an international task force led by UNIGE and HUG, and composed of scientists from twenty-eight institutions, is laying the foundations of a preventive protocol that could be implemented on a large scale.
“We based this protocol on the experience of all members of the task force. Some of the recommended interventions are ready to be applied or are already applied. Others are still under development”, explains Giovanni Frisoni, Full Professor of Clinical Neurosciences at the UNIGE Faculty of Medicine and Director of the HUG Memory Centre.
Professor Frisoni and the co-authors of the article have identified four pillars of this new concept in the field of dementia and Alzheimer’s: risk assessment; risk communication; risk reduction and cognitive enhancement.
1) Risk assessment. Risk factors for Alzheimer’s disease or related disorders and their weights were grouped into a rating grid. These include factors associated with genes, such as APOE4, or those related to lifestyle or conditions, such as high blood pressure, diabetes, alcohol use, social isolation, obesity, hearing loss, depression or head injury.
2) Risk communication. This second pillar, decisive in the relationship established with the patient, allows the risk index to be communicated in the most accurate and understandable way. In fact, understanding your risk of developing a disease is more complex than understanding that you actually have a disease. A series of recommendations based on the patient’s personality and background allow choosing the best tools to present the situation to the patient in an understandable way.
3) Risk reduction. Pharmacological and non-pharmacological risk reduction interventions are proposed. These range from lifestyle improvements to cognitive training and the administration of anti-amyloid drugs, if available on the market. Interventions on the gut microbiota could also be considered in the future.
4) Cognitive reinforcement. Different types of memory (subjective, objective, meta) can be strengthened or stimulated through paper exercises or computer games. Transcranial electrical or magnetic stimulation will also be an important tool for activating synapses in key regions of the brain and thus improving memory.
These four pillars described in detail in the article by The Lancet Regional Health—Europe will enable second generation memory clinics to reach the segment of the population whose memory is still functioning well and who wish to preserve or improve it. This population does not find answers in current clinics.
In Italy, according to the ISS EpiCenter: “In Italy, since 1987, some population studies have been conducted to estimate the prevalence and incidence of AD (1-7). Of the fifteen municipalities involved in these epidemiological surveys as a whole, 47% are located in the Centre, 33% in the North and 20% in the South. On the basis of the results of these studies, an attempt was made to estimate the prevalence and incidence of AD in the Italian population.
In the Table the main characteristics of the Italian studies are summarized. The largest study is the ILSA (Italian Longitudinal Study on Aging), which used a two-phase approach: in the first, the people included were interviewed on the presence of any signs and symptoms of the disease; subsequently, all persons with a Mini-Mental State Examination (MMSE) score of less than 24 or with a previous diagnosis of dementia referred by a family member were visited for diagnostic confirmation.
Of the 5,462 people eligible for the ILSA study, 3,645 (66.7%) had dementia screening completed. An important difference with the other studies is that the population included in ILSA is aged between 65 and 84 years with the elimination of the age groups with the highest prevalence of AD. The ILSA study also presents a high percentage of people for whom the type of dementia has not been diagnosed. In fact, while the prevalence for all dementias is quite in line with that observed in Europe (about 6%), that for AD is about half (2.5% vs 4.4%).
Among the remaining five studies, prevalence estimates ranged from 2.6% to 6.8%. Only those conducted in the towns of Appignano (MC) and Vescovato (CR) have similar characteristics: they use the same screening tool (AMT – Hodkinson Abbreviated Mental Test), the same clinical criteria (NINCDS-ADRDA) and present specific data by sex and age. For this reason, the estimation of the prevalent cases of AD in Italy was carried out considering the ILSA study and those of Appignano and Vescovato separately.
The age-sex specific prevalence reported in the ILSA study was applied to the 2001 Italian population in the 65-84 age group (n. 9,303,042). This allowed us to estimate approximately 238,000 expected cases of AD equal to a total prevalence of 2.6% (95% CI 2.0-3.1) with a range of expected cases between 184,000 and 292,000. On the other hand, considering the Appignano and Vescovato studies together, a specific age-sex cumulative prevalence was estimated and applied to the Italian population in 2001 aged over 60 (n. 14,037,876).
The expected number of AD cases was estimated at about 492,000, equal to a total prevalence of 3.5% (95% CI 2.5-4.5) with an expected range of cases between 357,000 and 627,000.
As regards the incidence of AD, the only study available in Italy was carried out on the population identified in the ILSA study (7). To estimate the incidence, the cohort of 3,208 healthy people from 1992-93 was reevaluated in 1995. Thus, 67 incident cases of AD were identified, according to the clinical criteria set by the NINCDS-ADRDA, equal to a crude rate of 7.0 cases per 1,000 person-years (95% CI 5.3-8.7). The estimate is higher in women (9.3; 95% CI 6.5-12.2) than in men (5.0; 95% CI 3.0-6.9).
The application of the specific age-sex rates observed in this study to the Italian resident population in 2001 allows us to estimate approximately 65,000 incident cases of AD expected in one year (95% CI 43,000-87,000).
The studies on the frequency of dementia were conducted in Italy on a small number of subjects and with little attention to the estimation of the different clinical forms and the different stages of dementia (mild, moderate, severe).
All this makes the epidemiological estimates uncertain both in terms of overall knowledge of the phenomenon, and as regards the extent of the differences between vascular dementia and AD (the former being more preventable through population-level control of cardiovascular risk factors). Despite these limitations, however, the estimate of the prevalent cases of AD in Italy, carried out taking the studies of Appignano and Vescovato as a reference, is in line with the data of the international literature.
Currently, dementias constitute a set of incurable pathologies that must be faced with a global approach to the care of the people affected, because the involvement of the person and his family is global and progressive. Since the drugs used in the treatment of dementias (cholinesterase inhibitors, neuroleptics, antidepressants, benzodiazepines, etc.) have a very limited therapeutic value, the need for strong planning is evident in relation to other non-pharmacological therapeutic approaches and to the welfare aspects of the sick and their family members.
In this regard, it must be remembered that there is some evidence in the literature showing that an intervention on the network of services is effective and efficient in modifying the natural history of dementia. Finally, primary and secondary prevention strategies of the phenomenon of dementia oriented towards the modification of lifestyles and cardiovascular risk factors must be implemented”.
In the world, according to WHO data: “OMore than 55 million people live with dementia, a major cause of disability and dependency among older people. An important figure, even more striking as it grows on a daily basis, with forecasts reaching 78 million by 2030″.
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