Dementia: Paradox prognosis

20. May 2014

If our society is to keep getting older, we will have to get used to living among many people with dementia. But will it really be as bad as health prophets predict? Study results of the last three years have surprised even experts.

The latest figures could make us doubt about whether we really want to live longer and longer, because the opinion researchers of professional associations which have described dementia and Alzheimer’s disease say that we can expect a heavy burden of sufferers in the coming decades.

80 Percent of nursing home residents have dementia

A sense of urgency has already penetrated the highest political circles. Maintenance costs are likely to weigh so heavily on government budgets in industrialised countries that in December last year even the G8 Summit of Ministers of Health in London dealt with the theme “Dementia in Old Age”. The international Alzheimer’s Association estimates the current number of patients with dementia to be around 44 million. For the year 2050 it forecasts three times that number, around 135 million sufferers. With regard to Germany as well many anticipate a similar development, not just for Alzheimer’s, but for dementia patients in general: given the current number of 1.4 million age-related cases of people with reduced mental faculties a rise should be expected to around three million people by mid-century. If this prediction comes to be, the state would be spending about one percent of its gross domestic product on the care of these people. The rate of demented residents in nursing homes will rise from the current 60 percent to 80 percent.

Surprising curves

But there are also curves that point in a different direction: Several studies show that the number of cases, at least based on one age group, is rather going down again. In July last year Lancet published a comparison of two UK studies of dementia development spaced twenty years apart. While prevalence more than 20 years ago still sat at 8.3 percent, the second study from the years 2008-2011 using the same methods of investigation presented the researchers with a substantial but pleasant surprise, because instead of a constant or even increasing rate, the rate now stood at 6.5 percent.

A Danish study done in two parts at a distance of ten years compared people who were born respectively in 1905 and 1915. For those with similar physical health, the later born made a much better impression in terms of mental fitness. Finally, one report in the New England Journal in November last year put five large studies done on dementia development in the USA, Sweden, United Kingdom and the Netherlands under the microscope. Eric Larson from Seattle and his colleagues from San Francisco and Ann Arbor have revealed a decrease in severe dementia among the over-65s in the U.S. – from 5.7 to 2.9 percent between 1982 and 1999. In the so-called “Rotterdam Study” the incidence of dementia fell among people over 55 from 6.5 cases per 1000 people in 1990 to 4.9 cases ten years later. There is importance in these figures in relation to the distinction between incidence and prevalence. So it may well be with the sharp increase in the upper part of the age pyramid that the prevalence of dementia still could increase slightly, although the number of new cases of diminished mental faculties decreased, says Larson.

Larger brain volume – fewer strokes

If one goes into the numbers of the Dutch investigation a little more in detail it is striking that the rate particularly for people aged between 70 and 79 fell within ten years by half. Additional MRI studies confirmed the test results. The later born group had a larger brain volume. Strokes with them occurred more rarely.

Thus, it appears that ageing alone is not automatically responsible for the crumbling of mental faculties. Responsible for the slow clouding of the brain in addition to Alzheimer’s disease in particular are vascular dementia and other more rare forms of dementia. Mixed forms are not uncommon especially among the very elderly. With few exceptions, lack of mental sharpness hardly affects our lives before age 60. Even in the ten years after that it only hits us with a probability of one percent. However then there is a steep rise: by eighty years of age one in twenty is suffering from dementia.

Cognitive Reserve

What could it be then that, despite problems with obesity, vascular diseases and diabetes, is keeping us mentally fit in increasing numbers? Experts tend in their observations to lean toward a mixture of various influencing factors. There is a constant use of the term “cognitive reserve” here. Intense social interaction between friends and acquaintances, whether virtual or real, challenges the brain to constantly perform. This also applies to games and to the wide range of possibilities for the elderly to learn a language or a new musical instrument. Whoever in these ways continuously build new connections within the brain can, in the case of failure of a brain region, probably more easily bring about a “switch over”. Very individualised training sessions via games could provide an extra memory reserve as well.

There’s also knowledge that regular exercise and sports have powers that could help in ensuring that the central nervous system is consistently well supplied with blood and relevant important blood factors. Paul Thompson, a neurologist from Los Angeles, states: “With ten percent loss of brain substance or more, we are able to measure cognitive impairments; and three percent of this loss can be spared through regular exercise alone”. Finally, it seems in a similar way to vascular diseases that the diet is also one of these significant factors working against mental degradation. For instance, folic acid and other B vitamins reduce homocysteine levels, which at high levels damage blood vessels, therefore contributing to reduced power supply in the brain.

Healthy lifestyle reduces the risk considerably

A few months ago Peter Elwood and his colleagues from the British cities Cardiff and Bristol published data in PloSOne which was derived from 2000 Welsh people whose life habits were observed regularly over a long-term study for 35 years. The result of the evaluation: Whoever suitably observes a healthy diet without consuming excessive amounts of alcohol and nicotine, while paying attention to exercise and weight, reduces the risk of both the moderate loss of brain power as well as dementia by about two thirds.

Genetic predisposition for mental longevity and regional environmental factors would, however, be less easy to influence. Gabriele Doblhammer from the Center for Neurodegenerative Diseases in Rostock found out in a European study that people who had the good fortune to be born in times of economic upswing have much better chances of ageing without too much mental degeneration.

Dementia Care – outsourced

“Two-thirds of people with dementia are still cared for at home. Things will not go on this way”, predicts Hans-Jürgen Freter, spokesman for the German Alzheimer’s Society, about future developments on the matter of age-based mental degradation. When the costs of care for the patient exceed labour costs, the health care system encounters its limits. New models for the financing and also “outsourcing” of care are the subject of intense scrutiny. Such an example is able to be seen in a recent story about a nursing home for German-speaking dementia patients in Thailand, a program which for the time being is still aimed at providing relief for their families by keeping these patients for a few weeks or months. However, long-term care of patients is not something the operator wants to exclude. Such “round the clock” care would in Europe only be affordable for the well off.

When looking at the rather declining rate of dementia alongside simultaneous increasing life expectancy, some are already talking about the existence of interest-motivated dissemination of doom and gloom. Precise research on an exact cause which explains the really encouraging figures is still pending. So far we do not know exactly why the rate is receding for women more sharply than for men and which influences have which sort of effect during early childhood on the ageing brain. Quite certain, however, is that a lifestyle that is good for the heart and for the circulatory system also keeps our brain intact longer.

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