Dementia

Dementia prevention, intervention, and care Gill Livingston, Andrew Sommerlad, Vasiliki Orgeta, Sergi G Costafreda, Jonathan Huntley, David Ames, Clive Ballard, Sube Banerjee, Alistair Burns, Jiska Cohen-Mansfield, Claudia Cooper, Nick Fox, Laura N Gitlin, Robert Howard, Helen C Kales, Eric B Larson, Karen Ritchie, Kenneth Rockwood, Elizabeth L Sampson, Quincy Samus, Lon S Schneider, Geir Selbæk, Linda Teri, Naaheed Mukadam
 Executive summary Acting now on dementia prevention, intervention, and care will vastly improve living and dying for individuals with dementia and their families, and in doing so, will transform the future for society. Dementia is the greatest global challenge for health and social care in the 21st century. It occurs mainly in people older than 65 years, so increases in numbers and costs are driven, worldwide, by increased longevity resulting from the welcome reduction in people dying prematurely. The Lancet Commission on Dementia Prevention, Intervention, and Care met to consolidate the huge strides that have been made and the emerging knowledge as to what we should do to prevent and manage dementia. Globally, about 47 million people were living with dementia in 2015, and this number is projected to triple by 2050. Dementia affects the individuals with the condition, who gradually lose their abilities, as well as their relatives and other supporters, who have to cope with seeing a family member or friend become ill and decline, while responding to their needs, such as increasing dependency and changes in behaviour. Additionally, it affects the wider society because people with dementia also require health and social care. The 2015 global cost of dementia was estimated to be US$818 billion, and this figure will continue to increase as the number of people with dementia rises. Nearly 85% of costs are related to family and social, rather than medical, care. It might be that new medical care in the future, including public health measures, could replace and possibly reduce some of this cost. Dementia is by no means an inevitable consequence of reaching retirement age, or even of entering the ninth
Lancet 2017; 390: 2673–734 Published Online July 20, 2017 http://dx.doi.org/10.1016/ S0140-6736(17)31363-6 See Comment pages 2614 and e51 Division of Psychiatry, University College London, London, UK (Prof G Livingston MD, A Sommerlad MSc, V Orgeta PhD, S G Costafreda PhD, J Huntley PhD, C Cooper PhD, Prof R Howard MD, N Mukadam MSc); Camden and Islington NHS Foundation Trust, London, UK (Prof Gill Livingston, S G Costafreda, C Cooper, Prof R Howard); Department of Old Age Psychiatry, King’s College London, London, UK (J Huntley); National Ageing Research Institute, Parkville, VIC, Australia (Prof D Ames MD); Academic Unit for Psychiatry of Old Age, University of Melbourne, Kew, VIC, Australia (Prof D Ames); Medical School, University of Exeter, Exeter, UK (Prof C Ballard MD); Centre for Dementia Studies, Brighton and Sussex Medical School, University of Sussex, Brighton, UK (Prof S Banerjee MD); Centre for Dementia Studies, University of Manchester, Manchester, UK (Prof A Burns MD); Department of Health Promotion, School of Public Health, Sackler Faculty of Medicine (Prof J Cohen-Mansfield PhD), Heczeg Institute on Aging (Prof J Cohen-Mansfield), and Minerva Center for Interdisciplinary Study of End of Life (Prof J Cohen-Mansfield), Tel Aviv University, Tel Aviv, Israel; Dementia Research Centre, University College London, Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK (Prof N Fox MD); Center for Innovative Care in Aging, Johns Hopkins University, Baltimore, MD, USA (L N Gitlin PhD); Department of Psychiatry, University of Michigan,
Key messages
1 The number of people with dementia is increasing globally Although incidence in some countries has decreased.
2 Be ambitious about prevention We recommend active treatment of hypertension in middle aged (45–65 years) and older people (aged older than 65 years) without dementia to reduce dementia incidence. Interventions for other risk factors including more childhood education, exercise, maintaining social engagement, reducing smoking, and management of hearing loss, depression, diabetes, and obesity might have the potential to delay or prevent a third of dementia cases.
3 Treat cognitive symptoms To maximise cognition, people with Alzheimer’s disease or dementia with Lewy bodies should be offered cholinesterase inhibitors at all stages, or memantine for severe dementia. Cholinesterase inhibitors are not effective in mild cognitive impairment.
4 Individualise dementia care Good dementia care spans medical, social, and supportive care; it should be tailored to unique individual and cultural needs, preferences, and priorities and should incorporate support for family carers.
5 Care for family carers Family carers are at high risk of depression. Effective interventions, including STrAtegies for RelaTives (START) or Resources for Enhancing Alzheimer’s Caregiver Health intervention (REACH), reduce the risk of depression, treat the symptoms, and should be made available.
6 Plan for the future People with dementia and their families value discussions about the future and decisions about possible attorneys to make decisions. Clinicians should consider capacity to make different types of decisions at diagnosis.
7 Protect people with dementia People with dementia and society require protection from possible risks of the condition, including self-neglect, vulnerability (including to exploitation), managing money, driving, or using weapons. Risk assessment and management at all stages of the disease is essential, but it should be balanced against the person’s right to autonomy.
8 Manage neuropsychiatric symptoms Management of the neuropsychiatric symptoms of dementia including agitation, low mood, or psychosis is usually psychological, social, and environmental, with pharmacological management reserved for individuals with more severe symptoms.
9 Consider end of life A third of older people die with dementia, so it is essential that professionals working in end-of-life care consider whether a patient has dementia, because they might be unable to make decisions about their care and treatment or express their needs and wishes.
10 Technology Technological interventions have the potential to improve care delivery but should not replace social contact.