Source: MHE Publication, MHE March 2022, Volume 32, Issue 3
There’s no guarantee, but physical activity and corralling cardiovascular risk factors and diabetes improve the odds. Health insurers can assist by helping members address the “upstream” social determinants of health.
Dementia is one of the most common and dreaded conditions in the United States. According to the CDC, about 5 million Americans have Alzheimer’s disease, the most common dementia diagnosis among older adults. Others estimate the prevalence at 6.1 million. By 2060, this number is expected to climb to 13 million.
“These numbers are projected to increase because elderly individuals are the fastest-growing segment in the United States,” says Claudia H. Kawas, M.D., a professor in the Department of Neurology at the University of California, Irvine, School of Medicine.
Alzheimer’s is the fifth-leading cause of death among Americans 65 and older and the sixth-leading cause of death in the U.S.
Dementia — especially Alzheimer’s as the best known cause of dementia — is also one of the most feared conditions in the U.S. “People are afraid of the uncertainty surrounding risks and developments, and the thought of losing their independence,” says Mateo P. Farina, Ph.D., a scientist at the Leonard D. Schaeffer Center for Health Policy & Economics at the University of Southern California. With heart disease or diabetes, there are proven ways to treat and manage the conditions, notes Farina. Dementia, though, “feels out of someone’s control,” he says.
“People also fear losing themselves and becoming a burden on their loved ones,” Farina continues. Someone with dementia will have personality changes, may need to alter their living circumstances and will require an immense amount of care from loved ones as well as medical doctors.
Dementia is influenced by many factors, including genetics, age, living situation, lifestyle and various medical conditions.
“When a patient presents with multiple components, there is a compounding effect that can negatively impact the body and lead to an earlier onset,” says Elizabeth Marshall, M.D., MBA, director of clinical analytics at Linguamatics, an IQVIA Company.
Although dementia is often equated with Alzheimer’s, there are other forms with well-characterized underlying pathologies. Frontotemporal dementia, for example, is associated with abnormal accumulations or forms of the tau and TDP-43 proteins in the brain. Lewy body dementia is caused by namesake Lewy bodies, deposits of a protein called alpha-synuclein. Vascular dementia is caused by brain damage that is the result of impaired blood flow.
Poor and disadvantaged individuals are at much higher risk of developing dementia for many reasons. In those who are genetically susceptible, limited access to healthy food and healthcare is a factor. Some research has linked vitamin deficiencies to the development of Alzheimer’s disease. Healthy foods are often good sources of the B vitamins and vitamins D and E, as well as omega fatty acids needed for proper brain health, notes Marshall.
Workplace and home environments are another thread in the web of factors affecting dementia risk. Someone who works in a factory with potential exposure to toxic chemicals might be at increased risk of dementia, depending on the chemical. Disadvantaged people are more likely to live in places that are near sources of pollution and toxic chemicals.
Research has consistently shown an association between high blood pressure and Alzheimer’s disease. Observational studies suggest that treating high blood pressure counteracts the risk, although the evidence from randomized trials is less certain. There’s also a large body of research suggesting that physical activity may help keep the brain healthier, especially when coupled with avoiding risk factors for cardiovascular disease (obesity and smoking) and managing conditions such as diabetes.
Education level also plays a significant role in dementia risk. Studies have shown an association between education levels and brain function, with high levels linked to better brain function and low levels to worse function, points out
Dennis B. Liotta, M.D., MBA, chief medical officer at Florida Community Care in Miami. Studies have shown that among adults 45 or older, the proportion experiencing subjective cognitive decline was lowest for college graduates and nearly three times greater for those without a high school diploma. “Although researchers don’t have a definitive cause, one theory is that lower education levels and the risk of developing dementia are related to ‘cognitive reserve,’ ” explains Liotta.
The cognitive reserve hypothesis is that some people may experience little or no dementia despite pathological changes in their brain that in people with less cognitive reserve would result in dementia and that, furthermore, this cognitive reserve tends to be associated with education level.
Reducing the chances
Although many of the risks for dementia occur in adulthood, researchers have also traced them back to childhood exposures and experiences.
“A child’s socioeconomic conditions can help shape risk at an important early developmental period that is then carried forward,” says Hyungmin Cha, M.A., a doctoral student at the Population Research Center at The University of Texas at Austin.
Although a disadvantaged childhood cannot be fully overcome, upward mobility as evidenced through greater education levels and wealth can significantly reduce both dementia risk and years of life spent in that dependent state, Cha says. This finding suggests that although socioeconomic circumstances are additive, the magnitude of their effect on cognitive health risk
The things known about dementia risk that are potentially modifiable are all related to general health and maintenance of health, says Kawas, noting the association between control of high blood pressure and cholesterol levels and a lower risk of dementia. Marshall says keeping the brain active is a way to reduce dementia. Socializing can stimulate the brain with conversation and debate. Education is also good “brain exercise” and can include simple tasks such as learning a new word each day, doing puzzles such as Wordle or reading about current events.
Access to healthcare can also modify the risk of Alzheimer’s. “Providing access to care through health insurance coverage will increase the number of people who receive screening and early treatment of chronic diseases such as hypertension, diabetes and heart disease,” notes Michael Dulin, M.D., Ph.D., chief medical officer at Gray Matter Analytics. “These preventative actions can, in turn, result in lower rates (of dementia) or delay in onset of dementia.”
The treatment options for Alzheimer’s disease are limited. Cholinesterase inhibitors such as Aricept (donepezil) are modestly effective in slowing the worsening of dementia. Last year, the FDA approved Aduhelm (aducanumab), a treatment targeting beta-amyloid protein deposits that many experts believe are an underlying cause of Alzheimer’s. But the approval of Aduhelm is the most controversial FDA decision in recent memory because it’s not clear from the clinical trials done so far whether the drug improves the clinical manifestations of the disease — in other words, the dementia. CMS has proposed limiting Medicare coverage of the drug to patients who are enrolled in clinical trials.
How insurers might help
Health insurers have started to move “upstream” to address the social determinants of health (SDOH). They are tackling food insecurities by providing healthy meals, encouraging people with conditions, such as diabetes to join support groups, and launching efforts to combat loneliness. Social isolation, which is related to loneliness, has been linked to dementia.
Kawas says health insurers should offer incentives that support behaviors known to result in better health outcomes. “Enough studies have been done to show that exercise is good for body health, heart health and brain health,” she says. “What we need to do is to figure out how to modify behaviors so that people will actually do that exercise and live a healthy lifestyle. Health insurers should take care of us as healthy people, not just pay the medical bills, and anything they can do to encourage healthy lifestyle throughout the life span.”
Providing incentives for their members to get regular checkups and maintain a primary care home would be another step insurers could take, Dulin says. In addition, identifying members with adverse SDOH, such as inadequate housing or poor access to healthy food, can be an important step for insurance companies looking to reduce the burden of dementia. Once this information is available, insurers can advocate for policy changes that provide better food access or assist their members by sharing this information directly with them and their healthcare providers.
Karen Appold is a medical writer who lives in the Lehigh Valley region of Pennsylvania.