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Targeting dementia's key risk factors may be far more effective than seeking a cure

Targeting dementia's key risk factors may be far more effective than seeking a cure
Alexa Soule, Stephan Rabie and John Joska
By Alexa Soule, Stephan Rabie and John Joska
5 Sep 2024
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The number of persons who will develop dementia in old age is increasing. By 2050, nearly 700,000 South Africans could be living with dementia — a significant increase from the 240,000 estimated cases in 2019.

As the population ages, the global burden of people with dementia is expected to rise exponentially. For this reason, the World Health Organization (WHO) considers dementia a public health priority across the world, especially in low-resource settings.

Despite four decades of clinical trials, there is still no cure for dementia. Our hope may lie in prevention: growing evidence suggests that dementia can be delayed by targeting key modifiable risk factors. As the world grows older, there are promising intervention strategies that can reduce the global dementia epidemic.

The growing risk with ageing


The biggest risk factor for developing dementia is old age. This is good news and bad news: the good news is that we’re living longer; the bad news is that with age comes an increased risk of dementia.

In sub-Saharan Africa, the number of people aged 60 and above is expected to triple by 2050. According to the latest census data of 2022, there are 5.6 million South Africans aged 60 or older, and this number is rising fast.

At the same time, the number of persons who will develop dementia in old age is increasing. By 2050, nearly 700,000 South Africans could be living with dementia – a significant increase from the 240,000 estimated cases in 2019.

Understanding different types of dementia


But what exactly is dementia? Dementia is an umbrella term used to describe diseases of the brain that lead to memory loss, impaired thinking, and changes in personality.

The most common types, particularly among those over 65, are Alzheimer’s disease and vascular dementia. Alzheimer’s disease accounts for the majority of dementia cases, characterised by the gradual worsening of memory and cognitive function.

Younger persons may lose brain function for other reasons, including traumatic brain injuries (of which there is a silent epidemic), alcohol abuse, and poorly controlled HIV. These types of dementia often present differently, with more varied symptoms depending on the underlying cause.

For many families in South Africa, the impact of dementia is profound. The person may need help with the most basic tasks, and as the disease progresses, it often becomes unsafe to leave the person alone.

The financial burden of care, whether in specialised facilities or through home-based care, is immense and often unaffordable. Some family members may even need to quit their jobs to provide care, adding to the financial strain on the household.

And this does not even begin to touch on the emotional stress and strain that is placed on the family.

Understanding Alzheimer’s


The exact cause of Alzheimer’s disease remains a mystery, though it probably involves a combination of genetic and lifestyle-related factors. These variables interact with each other to trigger the accelerated loss of nerve cells, or neurons, starting first in the brain’s memory centres, and spreading through the brain over the ensuing years.

In its wake, the brain is left with protein remnants called amyloid and tau, probably due to uncontrolled inflammation and neurodegeneration. While some medications, like cholinesterase inhibitors, show modest success in reducing symptoms, they are not a cure and are often too expensive (more than R300 per month) for many South Africans.

Newer amyloid-removal drugs have shown early promise, but with significant risks for trial participants. Africans have not participated in these trials. In this context, an ounce of prevention is worth a pound of cure.

Lancet Commission


Imagine being able to cut nearly half of all dementia cases just by making a few changes to your daily routine. That’s what the Lancet Commission on Modifiable Risk Factors suggests is possible. Their latest 2024 report highlights 14 key risk factors that, if addressed, could prevent or delay up to 45% of dementia cases. These factors are amenable to modification — they’re things we can all work on, like how much we move, what we eat, and how we manage chronic conditions like high blood pressure.

The evidence is clear: if we focus on these specific areas, we can significantly reduce the number of people affected by dementia as they age.

The need for action


The fact that we know about preventable risk factors for dementia should prompt action from individuals, communities and policy makers. However, most data on dementia prevention comes “disproportionately from high-income countries”, leaving gaps in understanding of how these factors apply in less-resourced settings like South Africa.

We’re missing key information, including the impact of HIV, a known cause of brain damage in persons not taking antiretroviral therapy. The condition known as “poverty” is also not included, with all its related challenges, including food security and good nutrition.

Early life


Dementia prevention isn’t just a concern for later in life; it’s something we need to think about across the entire lifespan. In early life, good education is essential. Education strengthens the brain, building protective mechanisms that help defend against the genetic and lifestyle factors that accumulate throughout life.

Unfortunately, in South Africa low education levels and limited access to quality schooling leave many individuals more vulnerable to cognitive decline as they age. Policymakers must understand that education is not just about learning; it’s a critical component of health. Investing in education is investing in long-term cognitive health.

Mid-life


Mid-life is when key lifestyle and health factors come into play – things like hearing loss, high LDL cholesterol, depression, traumatic brain injury, physical inactivity, diabetes, smoking, hypertension, obesity, and excessive alcohol. Together, these account for 30% of the reversibility quotient.

But in South Africa, our healthcare system is already strained by years of underfunding and the impact of austerity measures. This means that managing simple chronic conditions like hypertension and diabetes is a major challenge.

The solution? Living a healthy life: regular exercise, no smoking, moderate drinking, and eating well. Simple, right? But reality isn’t that neat. Our busy lives push us toward fast food and processed meals, which are typically high in calories and low in quality and nutrition, while the idea of growing our own food or cooking fresh feels like a relic of the past.

It does seem foreign to us to be able to plant and grow our own food, walk to market to buy it fresh, and prepare from scratch, rather than call up Uber Eats. And that’s if you’re in the upper socioeconomic bracket. For those just trying to get by to afford the basic necessities, healthy choices aren’t even on the radar.

Recent research suggests that up to 73% of our population is experiencing food insecurity. When you’re struggling to put any food on the table, how do you even think about eating healthily or exercising?

Then there’s the issue of mental health. South Africa has one of the highest rates of trauma in the world, with high levels of violence and disorders like depression. The Lancet Commission points out that untreated depression can significantly increase the risk of developing dementia.

But in our context, with mental health services scarce, stigmatised, and out of reach for many, too many people are suffering in silence and left to cope on their own.

Late life


In late life, factors like social isolation and visual loss start to chip away at brain health, accounting for about 10% of the preventable risk. Simple things like staying socially engaged and getting your eyes checked regularly can make a big difference.

While these may seem aspirational, they are achievable in the right environment. Look at the communities featured in Dan Buettner’s Netflix series “The Blue Zones” – places where people live longer, healthier lives by eating well, moving often, and staying connected.

But let’s face facts: these communities are rare, and none were found in the Global South. The takeaway? Eat well, move more, stay positive, and build strong social connections. But we can’t do it alone.

Collective action


Preventing dementia isn’t just possible — it’s necessary, but it requires collective action. The simple habits needed to break bad diets, sedentary living, stressful lives and fear of healthcare are developed in families and communities.

From individuals making healthier choices, to communities supporting each other, from policymakers prioritising education to healthcare providers making care accessible, everyone has a role to play. These are our best weapons in the fight against dementia. We need to start these conversations now.

The time to act is now. Whether it’s making healthier choices for yourself, supporting local initiatives, or advocating for better policies, every small step can contribute to a future where dementia is no longer an inevitable part of ageing.

If you or someone you know is struggling with dementia, non-profit companies like Dementia SA and Adasa (Association for Dementia and Alzheimer’s of South Africa) provide helpful resources and offer training on dementia care for a minimal cost. DM

Alexa Soule is a Junior Research Fellow and neuropsychologist in the HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, at the University of Cape Town (UCT).

Stephan Rabie is a Research Psychologist and Senior Research Officer in the HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, at UCT.

John Joska is Head of Clinical Services (Psychiatry) at Groote Schuur Hospital and Director of UCT’s HIV Mental Health Research Unit.

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