Prioritizing Cognitive Decline And Dementia Prevention In Older Adults

According to a Gerontological Society of America's 2019 report, "one of the biggest trends is an emphasis on cognitive decline, cognitive change, dementia in all phases." Not only is cognitive well-being a fundamental determinant of positive aging, but the human and healthcare cost of cognitive decline are momentous. And as the number of senior adults is projected to reach 20% of the U.S. population by 2025, attention to the various levels of vascular cognitive impairment (VCI) is a timely healthcare imperative.

What is vascular cognitive impairment (VCI)?

Cognition is a combination of brain processes, including the ability to learn, remember, and make judgments that guide a person's executive function and mobility. Cognitive decline includes mild cognitive impairment (MCI) to severe cognitive impairment (SCI). VCI is a more recent term that encompasses vascular and neurodegenerative dementias. Alzheimer's disease (AD) is the most common type of dementia, which affects 6.2M adults in the U.S. and is the fifth leading cause of death in adults over 65.

Cognitive impairment, including Alzheimer's disease, is projected to grow significantly as the older adult population increases

Extensive research published in 2021 by the Department of Health and Human Services (HHS) compared various projection models and used the Dynamic Simulation of Income Model (DYNASIM) to project the risk and costs of SCI over the coming decades. HHS determined that the number of people living with mild to severe cognitive impairment will nearly double by 2055. Research presented in 2021 by the Institute for Health Metrics and Evaluation puts global estimates nearly triple to more than 152M by 2050.

The HHS work estimates that "one in three of today's working-age adults who survive to age 65 will become severely cognitively impaired before they die, and 40 percent of those who become impaired will need care for five or more years."

Costs of dementia expected to double by 2040

According to a RAND study, "The monetary cost of dementia in the United States ranges from $159B to $215B annually, making the disease more costly to the nation than either heart disease or cancer." The per-person cost of dementia was $56,290 or $41,689. Medicare paid about $11B of dementia-related costs, which RAND says could more than double by 2040. 

Institutional and home-based long-term care is the highest economic cost of dementia. Some research shows negligible direct medical cost differences (doctor visits, hospital admissions, etc.) between people living with cognitive impairment and those without impairment. Other studies say that average annual direct medical costs per person are substantially higher for mild cognitive impairment – 44% higher.

In addition to institutional and direct medical costs are the cost of informal caregiving by family, friends, and community volunteers. The RAND study did include informal caregiving in its estimate above, which, when combined with the cost of nursing home care, and formal home care, comprises 75% to 84% of total dementia costs.

Medicare and health plans will bear these costs. Increasingly, so will individuals, their families, and states as informal care fill gaps and more older adults become dual-eligible for Medicare and Medicaid, as well as declare bankruptcy due to medical debt. Four in 10 adults in the U.S. have medical or dental debt. Of those, three percent have declared bankruptcy in the last five years. Nearly half of those owe more than $2,500.

Risk factors beyond age

Age is the number one risk factor for cognitive impairment. Prevalence rates typically increase from a few percent for adults in their 60s to 30% or 45% for adults in their 90s. Beyond age, however, a host of risk factors affect overall brain health but can contribute to or accelerate impairment and dementia. Twelve modifiable risk factors include chronic diseases, health conditions and behaviors include:

• High blood pressure
• Diabetes
• Smoking
• Obesity
• Lack of physical activity
• Poor diet
• Low levels of cognitive engagement
• High alcohol consumption
• Traumatic brain injury
• Depression
• Hearing loss
• Social isolation
• Air pollution

While genetics and gender are unmodifiable risks, other factors associated with increased dementia include chronic conditions like Parkinson's, heart disease, stroke, chronic kidney disease, HIV, delirium due to illness, medication side effects, and some developmental disabilities.

Risks related to social determinants of health

Other risk factors for dementia are related to social determinants of health (SDoH). Level of education and income are significant impactors. For example, people with less than high school education are about 60-75% more at risk for SCI. 

When combined with ethnic background, these risk factors highlight populations at greatest risk. Black and Hispanic Americans are more likely to become impaired than non-Hispanic White people. Women are more likely to become impaired than men, partly due to a longer life expectancy. Looking across these factors revealed that Latino and Black women who lived alone were the most at risk. 

Interventions show encouraging results to lower risk and decrease cost

• A Stanford study in 2020 tapped a program from the AgeWell Global pilot that utilized older adults to visit peers after hospitalization for companionship and screening. The program reduced 30-day readmission rates by 25%, estimating ongoing net annual savings could reach $483M. 
• A systematic review of previous research on interventions to prevent cognitive decline found that aerobic exercise (twice a week for 4-6 months) and one-to-three cognitive-motor challenges (like Tai Chi with simulated task exercises) had very good evidence to improve cognitive functioning. Creative art, resistance training, and Tai Chi at various intervals over a four-to-six-month period showed good evidence for improvement.
• A 2021 study published in the Annals of Internal Medicine found that dual-eligible patients had disability scores that were 28% higher than people not enrolled in both Medicare and Medicaid, and they were nearly 10 times more likely to develop dementia after a critical illness. They concluded that after a stay in the intensive care unit, all seniors, particularly dual-eligible patients, had a year to return to their baseline level of physical function or were at significant risk of cognitive impairment like dementia. This research highlights the need for timely post-ICU rehabilitation and cognitive assessments and the long-term risk of a greater need for nursing home stays, readmissions, and loss of independence.
• A virtual cognitive health program focused on older adults at risk for dementia experienced statistically significant improvements in their cognitive function, depression, and anxiety levels.
• Artificial intelligence (AI) socially assistive robots (SAR) were found in a meta-analysis study to improve cognitive function and hold promise as a nonpharmacological intervention that could be used for health notification, play therapy, counseling service, conversation, and dementia prevention programs.
• The Université de Montréal led research to identify the optimal number of individual treatment sessions for those with cognitive decline associated with dementia. The team determined that about 12 interventional sessions are needed to prevent cognitive decline in people at risk. Based on secondary analysis of a three-year Multi-domain Alzheimer Preventive Trial (MAPT), participants received a range of interventions, including dietary advice, physical activity, and cognitive stimulation to improve or maintain physical and cognitive abilities.

Two randomized controlled trials (RTCs) are currently active and exploring multi-modal approaches to prevent cognitive decline:

• Beginning in 2019, a three-year randomized controlled trial is investigating the effectiveness of a personalized multi-modal digital health intervention to prevent cognitive decline and potentially dementia. It is the largest Internet-based trial.
• The SINgapore GERiatric (SINGER) intervention is a two-year multi-site randomized controlled trial that uses a multi-domain lifestyle interventional approach shown effective in delaying cognitive decline by the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) trial. SINGER is part of the Worldwide-FINGERS international network investigating nonpharmacological interventions like dietary advice, exercise, cognitive training, and vascular risk factors management.

Accelerating the nation's response to cognitive decline and supporting brain health

Since President Obama signed the National Alzheimer's Project Act (NAPA) in 2011, Alzheimer's, dementia, and brain health has taken on a greater national focus. This groundbreaking legislation established the first-ever framework for a national strategic plan to address the Alzheimer's crisis and coordinate a response on multiple fronts, including research, care, and support. 

Today, the research indicates that dementias are on the rise and will continue to increase as more senior adults live longer, chronic conditions are better managed, and more people live with new chronic conditions. Whether the increase is from positive trends, like older adults living longer, or negative trends like more adults living with chronic disease, policymakers, researchers, healthcare organizations, and the adults and families they support, have an imperative to prevent cognitive decline and engage evidence-based multi-modal interventions to support brain health.

Driven to deliver evidence-based, practical solutions for clinical and business leaders that advance healthcare for everyone, RTI Health Advance experts support programs and interventions for older adults through digital health, care quality, population health, and health equity.

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