Alzheimer’s disease International (ADI) is the umbrella organization of 94 Alzheimer associations around the globe to campaign every September to raise awareness and challenge the stigma that surrounds dementia. September 2018 will mark the 7th World Alzheimer’s Month. ADI works in India through the Alzheimer’ s disease and Related Disorders Society of India (ARDSI established in 1992) and empowering ARDSI to promote and offer support to people with dementia and their care partners, and globally to focus attention on the epidemic and campaign for policy change. In a human era of heightened social sensitivity, and to mitigate social stigmatization, the term neurocognitive disorder (NCD), replaces the word dementia, to refer to a wide range of disorders that affect the brain.
As a neurologist, it is quintessential to realize that neurological disorders such as dementias, traumatic brain injury and stroke are now the hidden epidemic of ‘neurologic disability’ in India. India, the world’s second most populous country, is facing a ‘tsunami’ of this “hidden” epidemic. There is a substantial double burden of non-communicable disorders as well as communicable diseases. The Government of India and our parliamentarian friends should realize that is time for a ‘wake-up call’ and ‘time for action’ since these neurological disorders will assume an insurmountable public health issue. These neurological afflictions do certainly have the potential for disastrous outcomes on the mental capital of India with a young population demographics, premature mortality, and wellbeing of nations. Alzheimer ’s disease does represent one of the greatest challenges to the social fabric and health care systems of the world since the great plagues of the Middle Ages. Dementia, the ‘silver tsunami’ is indeed the next global pandemic or a non-communicable plague of the 21st century.
It is estimated that over 3.7 million people are affected by dementia in India. This is expected to double by 2030. The two most common causes of dementia are Alzheimer´s disease (AD) and vascular dementia. AD accounts for 50-70% of all cases of dementia, about 20-30% have either vascular dementia or a combination of vascular dementia and AD. To make matters worse, In India, there are less than 1200 neurologists with a ratio of one neurologist to 1,250,000 Indians. Furthermore, it is disappointing to note that there are only 90 institutes in India providing training to 200 neurology residents annually. Hence the ‘fight against dementia’ should be a multidisciplinary challenge involving primary care physicians, general physicians, geriatricians, psychiatrists, neurologists, medical social workers, and public health policymakers for the advocacy for dementia and ‘dementia solidarity’. There is a need on all fronts including government, NGOs, professionals, policy makers and people to create awareness and understanding of dementia and its impact in India.
Why ‘the route of prevention of dementia’? I would not wish to be a therapeutic nihilist at the beginning of this day, when much research is underway for novel anti-dementia drugs but I wish to reiterate that until such effective, curative or disease modifying drugs are available, both in the developed and developing countries cheaply; preventive strategies, understanding brain health and concepts for health Brain Ageing (HBA) will remain the Holy Grail in preventing or delaying the ravages of this progressive ‘chronic brain failure in India. HBA is a burgeoning field that proposes a link between brain health behaviours (brain healthy lifestyle) and maintenance of brain health Why preventive neurology strategies? I quote Louis Pasteur “When meditating over a disease, I never think of finding a remedy for it, but instead a means of preventing it” (1884). I also quote that “Epidemics can only be eradicated by prevention, not by therapy!”
The collective wisdom informs us that prevention strategies and roadmap for ‘healthy brain ageing’ is the wave of the future in the dementia healthcare crisis; health education, public campaigns should work towards radical policy shifts symbolizing ‘Healthy Brain Lifestyle 2030’ , ‘Brain Fitness’ to save our brains. We need to “use it or lose it” which refers to brain fitness for maintaining brain function and avoiding dementias. “Is dementia a curse that is inescapably linked to old age?” To move away from this pessimistic view of very old age, the story of the Okinawa Centenarians, the Nun study, and Kimberley indigenous Australian study did prove successful cognitive ageing and the concept of HBA and ‘Cognitive reserve hypothesis’.
Dementia is a ‘Lifestyle Disease’ and the public need to be taught regarding attitudes about Brain Health, brain well being and a “Life course approach-from the cradle to the grave” and how we can protect the brain. Can we ‘‘train’’ our brain to stave off the ravages of cognitive decline and dementia? Can we promote normal ‘Successful Brain Ageing’ during human longevity? Dementia is not an event, but the end stage of several pathophysiologic processes resulting in “chronic brain failure”. The focus needs to be shifted from the extreme category of dementia to the continuum of cognitive functioning that includes pre-symptomatic/pre-clinical stage that takes about 20-30 years to evolve to noticeable dementia; pre-dementia/prodromal dementia to clinically overt dementia.
The brain has a fantastic capacity to change for the better and is a “social organ”. This capacity to change with experience is called neuroplasticity (Brain’s cognitive reserve). Neuroplasticity involves the formation of new brain networks, new brain connections, strengthening of existing connections, the creation of new brain cells and increased survival of existing brain cells and brain connections. Strategies to protect and enhance the Brain’s cognitive, vascular and emotional health will be the key to promoting brain protection. The promising strategies for the prevention of dementia and promoting HBA will vascular risk factor control (improving cardiovascular health, hypertension, hypercholesterolemia, diabetes mellitus, obesity, metabolic syndrome, hyperhomocysteinemia), cognitive (mental) activity (learning, reading, playing games, sudokos, puzzle games, meditation, yoga) , physical activity, social engagement (leisure activities, walking, bicycling, gardening, playing musical instruments, social networking, visiting friends and relatives, going to movies. hobbies, spirituality, active socially integrated lifestyle), diet (eating ‘brain foods’), and early treatment of depression. Cognitive training, brain exercise (brain gym) can improve memory, reasoning, and mental processing speed in older adults. A ‘brain-healthy diet’ that is high in antioxidants, the Asian-Mediterranean diet, Curcumin (turmeric and Indian spices), diets high in fish, fruit, and vegetables, and our Indian heritage of religious fasting (calorie restriction), good sleeping habits, reducing heart attacks and strokes are all brain protective. HBA and understanding brain health in a deeper and broader concept, Understanding lifestyle and biological factors might alter the risk of dementia is crucial to preventing the disease. A combination of these lifestyle interventions is certainly multiplicative in its effects. More research is needed, but in my the most optimistic view, as a cognitive and behaviour neurologist and a dementia specialist, these pluralistic lifestyle interventions for HBA, Brain Well Being and Brain Fitness could prevent, delay, or shorten the course of dementia during the course of our human longevity. Dementia is not a destiny, and its cognitive trajectory could be influenced by HBA strategies, a life-course (cradle to grave approach) and practice of brain healthy lifestyles in our daily lives. HBA strategies and Preventive Neurology could alter the brain’s cognitive and emotional trajectory to one of a positive, creative, healthy and successful brain ageing thus keeping dementia at bay.
Prof Dr B.P. Shelley, MBBS, MD, DM, FRCP (UK)
Fellowship in Cognitive & Behavioural Neurology (UK)
Cognitive & Memory Disorders Clinic
Department of Neurology
Yenepoya Medical College
