The publication of a report by the International Commission on Dementia, ‘Dementia prevention, intervention, and care’, in the Lancet on July 20 was reported in this newspaper (July24) under the heading ‘Living healthily, learning more could cut dementia cases by a third’.
The report spanned all facets of dementia, including prevention, social and supportive care for patients and family and drug treatment. However it was the potential for the prevention of dementia, as estimated in this report that attracted great media attention.
As populations get older in Western countries, so people with age-related disorders will increase and health services will face a staggering increase in the cost of looking after elderly people.
Dementia could account for 40 per cent of these costs. A reduction in the toll of dementia – as well as other age-related disabilities – through lifestyle enhancement could therefore be of huge significance to state health funding.
Particularly high priority is now being given to enhancing ‘brain health’, starting in childhood with a robust scholastic education. The priority of the preservation of hearing and social inclusion of the aged were also upgraded. The role of poor diet, alcohol, smoking, exposure to pollution from living near major roads and disordered sleep, which are now accepted as significant risk factors for dementia, were not discussed at length in this report.
The pre-eminence given to hearing loss as a risk factor for dementia by the Lancet report is novel and intriguing. It is relevant to Malta where exposure to noise is almost universal.
The message is particularly urgent for youths who spend time driving in ‘mobile disco’ cars equipped with powerful amplifiers that deliver ear-shattering thumping ‘music’.
Staff at disco establishments are also exposed to inordinate noise which may result in premature deafness. Education is urgently needed to make people aware that they risk making themselves prematurely deaf from exposure to intense noise – which, in its turn, places them at a heightened risk of dementia in old age.
Malta has one of the highest adult and childhood obesity rates in the EU
The Lancet apportioned high priority to thorough primary and secondary school education to ensure lifelong brain health.
The case for a good scholastic education is based on the construct of enhancing ‘cognitive reserve’ or ‘cognitive capital’ in early life which is gaining currency and is now more widely accepted that cognitive resilience needs to be enhanced early in life to prevent dementia or delay its onset.
Though the Lancet relegates exercise to a lower priority than hearing and school education for prevention of dementia, exercise should remain pivotal in the scheme of preventive measures in Malta.
The results of a global survey on physical activity (Lancet, 2012) found that Malta is the least physically active country in the world with 72 per cent of Maltese qualifying as inactive.
This lack of physical activity is strongly linked to the way of life in Malta which is largely determined by our living environment. We have no mixed urban land use that generates multi-modal mobility so that there is no encouragement of healthy lifestyle choices or healthy mobility options such as public transport, walking or cycling.
Malta has one of the highest adult and childhood obesity rates in the EU. The prevalence of Type 2 diabetes is also unacceptably high. Both conditions are interlinked with physical inactivity and causation of dementia. Diabetes, in particular, is strongly associated with lack of exercise.
We have low-status public transport and no policies that favour pedestrians or cyclists. The end result is disproportionate car dependency combined with the antagonism of motorists to cyclists and virtual absence of bicycle commuting in the population.
Unlike other countries, Malta continues to give too much priority to private car transport so that fewer people build physical activity into their daily routine by choosing healthier mobility options.
We widen roads, create more car parks, build petrol stations on prime land; we even cut down valuable mature trees to facilitate vehicle traffic. Millions are spent on road improvement, but little on improving public transport or decent road infrastructure for other mobility options.
The Lancet report concludes unequivocally that more than one third of global dementia cases may be prevented by addressing modifiable lifestyle risk factors starting from childhood.
A key message of the Lancet report was: “Be ambitious about prevention because attention to these factors has the potential to delay or prevent a third of dementia cases.” The contents of the Lancet report reinforce the principle that education and health should be top priorities of good governance.
In December 2015, the Today Public Policy Institute (TPPI) published a thoroughly evidence-based report: ‘The Environmental Dimension of Malta’s ill-Health and action to prevent Obesity, Diabetes, Cardiovascular Disease and Dementia.’
In addition to prevention of dementia, this report included the prevention of obesity and Type 2 diabetes – both in themselves risk factors for dementia. In terms of prevention, the message in the Lancet report remains the same as that in the TPPI report except for some reordering of priority of some risk factors.
The importance of education, mental well-being and social engagement in old age are discussed at length in supplement IV of the 2016 TPPI report.
The TPPI report was widely distributed to all relevant government departments. It is ironical that this report, which has now been endorsed by the Lancet, was all but ignored.
Continuing complacency over our future health and the threat from obesity and diabetes, which in themselves are risk factors for dementia, will result in enormous health bills in the future.
George Debono is a retired doctor with a research background and a special interest in health and environment matters.