Preventing Dementia and Cognitive Decline: Difference between revisions

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== Introduction ==
== Introduction ==
[[File:Dementia 1.jpg|thumb]]The amount of people suffering from cognitive impairment or any type of dementia has been constantly on the rise. Around 50 million people suffer from dementia worldwide, with 10 million new cases every year. Some say the rise is due to the prolonged life expectancy, but it is important to note that although age is the strongest known risk factor for dementia, it is not a normal and inevitable consequence of aging. Dementia is one of the major causes of disability and dependency among older people. It has a physical, psychological, social and economic impact on people with dementia, but also their carers, families and society at large.<ref name=":0">Prince M, Wimo A, Guerchet M, Ali GC, Wu Yutzu, Prina M. World Alzheimer Report 2015. The global impact of dementia: an analysis of prevalence, incidence, cost and trends. London: Alzheimer’s Disease International; 2015</ref> As of date, no effective treatment of dementia and cognitive decline have been found - leaving an urgent need for preventive interventions.  
[[File:Dementia 1.jpg|alt=|right|frameless]]The amount of people suffering from mild [[Cognitive Impairments|cognitive impairment]] (MCI) or any type of [[dementia]] has been constantly on the rise. Around 50 million people suffer from dementia worldwide, with 10 million new cases every year. Although age is the strongest known risk factor for dementia, it is not a normal and inevitable consequence of [[Older People Introduction|aging]]<ref name=":0">Prince M, Wimo A, Guerchet M, Ali GC, Wu Yutzu, Prina M. World Alzheimer Report 2015. The global impact of dementia: an analysis of prevalence, incidence, cost and trends. London: Alzheimer’s Disease International; 2015</ref>.  


== General ==
The term [[dementia]] includes several diseases that are mostly progressive and affect the memory, other cognitive abilities and behaviour. The disease interferes significantly with one's ability to maintain [[Activities of Daily Living|activities of daily living]].
The term [[dementia]] includes several diseases that are mostly progressive and affect the memory, other cognitive abilities and behaviour. The disease interferes significantly with one's ability to maintain activities of daily living. The most common form of dementia is [[Alzheimer's Disease|Alzheimer disease]] (60-70% of prevalence). Other major forms of dementia include vascular dementia, [[Lewy Body Disease|Lewy bodies]] and a group of diseases that contribute to frontotemporal dementia. Mixed forms often coexist and boundaries between different forms of dementia are indistinct making it difficult to diagnose.<ref name=":1">Prince M, Albanese E, Guerchet M, Prina M. World Alzheimer Report 2014. Dementia and risk reduction: an analysis of protective and modifiable risk factors. London: Alzheimer’s Disease International; 2014 </ref>


With both mild cognitive impairment (MCI) and dementia there is objective evidence of cognitive impairment. The main distinction between the two terms is that with dementia, more than one cognitive domain is involved and that substantial interference with daily life is evident. Individuals with MCI have objective evidence of declination in cognitive impairment from the past, but they function independently or nearly so in their daily lives in a manner that is indistinguishable from the past.<ref>Knopman, David S., and Ronald C. Petersen. "Mild cognitive impairment and mild dementia: a clinical perspective." ''Mayo Clinic Proceedings''. Vol. 89. No. 10. Elsevier, 2014.</ref>
* '''MCI''' is generally defined as significant '''memory loss''' without the loss of other cognitive functions. People with MCI have more memory problems than would be expected from someone at a similar age. People with MCI are able to function independently and do not show other signs of dementia, such as impaired reasoning or judgment<ref name=":1">Dementia Australia [https://www.dementia.org.au/about-dementia-and-memory-loss/about-dementia/memory-loss/mild-cognitive-impairment MCI] Available: https://www.dementia.org.au/about-dementia-and-memory-loss/about-dementia/memory-loss/mild-cognitive-impairment (accessed 21.9.2021)</ref>.
* Dementia describes a collection of symptoms that are caused by disorders affecting the brain. It is not one specific disease.  Dementia affects '''thinking, behaviour''' and the '''ability to perform''' everyday tasks. Brain function is affected enough to interfere with the person’s normal social or working life.<ref name=":1" />


A common misconception is that dementia exclusively affects older people. Young onset dementia (the onset of symptoms before the age of 65 years) accounts for up to 9% of prevalence.<ref>Alzheimer’s Disease International and WHO. Dementia: a public health priority. Geneva: World Health Organization; 2012 </ref>
While there's currently no treatment that can prevent or cure dementia, researchers have identified some factors that may help protect you from cognitive decline.


Research has shown a relationship between the development of cognitive impairment and lifestyle-related risk factors that are shared with other noncommunicable diseases. These risk factors include:
== Protection factors from Cognitive Decline ==
* Physical inactivity
'''[[Therapeutic Exercise|Exercise]] -''' has many health benefits. It helps prevent [[Coronary Artery Disease (CAD)|heart disease]] and [[Diabetes Mellitus Type 2|type 2 diabetes]]; lowers the risk for [[Hypertension|high blood pressure]], [[Colorectal Cancer|colon cancer]], and [[Breast Cancer|breast cancer]]; and helps relieve insomnia, anxiety, and [[depression]]. In addition, it may help ward off cognitive decline and dementia.
* Obesity
 
* Some studies have shown that engaging in a program of regular exercise improved cognitive function in people who already had memory problems.<ref>Liu IT, Lee WJ, Lin SY, Chang ST, Kao CL, Cheng YY. Therapeutic effects of exercise training on elderly patients with dementia: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2020 May 1;101(5):762-9.</ref><ref>Hilfiker R. Exercise for older adults with mental health problems. InPrimary Care Mental Health in Older People 2019 (pp. 127-143). Springer, Cham.</ref>
* Exercise may be particularly advantageous for people who carry the APOE4 gene variant, which makes people more susceptible to [[Alzheimer's Disease|Alzheimer's.]]
* Sedentary behaviours increase psychological [[Stress and Health|stress]] and are a greater vascular and metabolic burden.<ref>Panahi, Shirin, and Angelo Tremblay. "Sedentariness and health: Is sedentary behavior more than just physical inactivity?." ''Frontiers in public health'' 6 (2018): 258.</ref>
[[File:Healthy food 2.jpg|right|frameless]]
'''A Mediterranean-style diet -''' Emphasizes fruits, vegetables, whole grains, beans, nuts and seeds, and olive oil, and includes moderate amounts of fish, poultry, and dairy products, while limiting red meat. This diet has long been recognized as promoting better cardiovascular health ,lowering the risk of certain cancers, and may protect against cognitive  decline.
 
* Studies point to the protective effect of eg omega-3 polyunsaturated fatty acids and vitamins B6, [[Vitamin B12 Deficiency|B12]] and folate, antioxidants (vitamin A, C and E) and [[Vitamin D Deficiency|vitamin D]].<ref>Hooshmand, Babak, et al. "Association of vitamin B12, folate, and sulfur amino acids with brain magnetic resonance imaging measures in older adults: a longitudinal population-based study." ''JAMA psychiatry'' 73.6 (2016): 606-613.</ref><ref>Rutjes, Anne WS, et al. "Vitamin and mineral supplementation for maintaining cognitive function in cognitively healthy people in mid and late life." ''Cochrane database of systematic reviews'' 12 (2018).</ref><ref>McCleery, Jenny, et al. "Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment." ''Cochrane Database of Systematic Reviews'' 11 (2018).</ref>
 
'''Alcohol'''
 
* Some older studies suggest that people who consume an average of one alcoholic beverage per day may have a lower risk of dementia. However, experts do not recommend drinking alcohol to prevent cognitive decline. If you enjoy an occasional alcoholic beverage, you should limit your consumption to no more one drink per day.
* In the JAMA study, heavy drinkers—defined as more than four drinks per day or 14 per week for men and more than three drinks per day or seven per week for women—had a 22% higher Alzheimer's risk than the nondrinkers.
* [[Alcoholism|Alcoholic]] dementia and Wernicke-Korsakoff syndrome are well-known possible consequences of excessive and long-term alcohol consumption.
* There is link between milder forms of MCI and dementia and alcohol abuse, which seems to cause neurotoxicity and neuroinflammation but also affects the brain directly by promoting nutritional deficiency.<ref>Day, Ed, et al. "Thiamine for Wernicke‐Korsakoff Syndrome in people at risk from alcohol abuse." ''Cochrane Database of Systematic Reviews'' 1 (2004).</ref>
[[File:Sleep baby.jpg|right|frameless]]
'''[[Sleep: Theory, Function and Physiology|Sleep]] -''' Getting consistent, good-quality sleep improves overall health and may prevent cognitive decline. We need a certain amount of regular sleep for a variety of essential functions, many of them in the [[Brain Anatomy|brain]]. People who regularly sleep less than the recommended seven to eight hours a night score lower on tests of mental function, possibly because learning and [[Memory|memories]] are consolidated during sleep.
 
'''Mental stimulation :''' Education level is less important in maintaining a healthy brain than the habit of staying mentally active as you age.<ref>Lövdén M, Fratiglioni L, Glymour MM, Lindenberger U, Tucker-Drob EM. Education and cognitive functioning across the life span. Psychological Science in the Public Interest. 2020 Aug;21(1):6-41.</ref><ref>Peeters G, Kenny RA, Lawlor B. Late life education and cognitive function in older adults. International Journal of Geriatric Psychiatry. 2020 Jun;35(6):633-9.</ref>
 
'''Social contacts -''' Social interaction can have profound effects on your health and longevity. Strong social connections may be as important as physical activity and a healthy diet. Social activities require you to engage several important mental processes, including attention and memory, which can bolster cognition. Frequent engagement helps strengthen neural networks, slowing normal [[Ageing and Changes in Other Systems|age]]-related declines. It may also help strengthen cognitive reserve, which can delay the onset of dementia<ref>Havard health Protecting against cognitive decline  Available: https://www.health.harvard.edu/mind-and-mood/protecting-against-cognitive-decline (accessed 21.9.2021)</ref>.
 
'''Reduce cardiovascular risk factors''' - Recent research shows the presence of heart disease and [[Heart Failure|heart failure]] has been associated with a 27% and 60% increased risk for dementia. The etiologic role of [[atherosclerosis]] in Alzheimer's disease is still controversial, but several studies have found correlations between carotid atherosclerosis and Alzheimer's disease. A systematic review by Chang et al, linked asymptomatic carotid stenosis to cognitive dysfunction, suggesting that subclinical changes are involved in cognitive decline when atherosclerosis is present.<ref>Wolters, Frank J., et al. "Coronary heart disease, heart failure, and the risk of dementia: a systematic review and meta-analysis." ''Alzheimer's & Dementia'' 14.11 (2018): 1493-1504.</ref><ref>Yan, Z., et al. "Carotid stenosis and cognitive impairment amongst older Chinese adults living in a rural area: a population‐based study." ''European journal of neurology'' 23.1 (2016): 201-204.</ref><ref>Chang, Xue-Li, et al. "Association between asymptomatic carotid stenosis and cognitive function: a systematic review." ''Neuroscience & Biobehavioral Reviews'' 37.8 (2013): 1493-1499.</ref><ref>Hofman, Albert, et al. "Atherosclerosis, apolipoprotein E, and prevalence of dementia and Alzheimer's disease in the Rotterdam Study." ''The Lancet'' 349.9046 (1997): 151-154.</ref>
 
'''[[Smoking and Exercise|Smoking]] -''' Tobacco is the major risk factor for cancer, [[Cardiovascular Disease|cardiovascular disease]] and dementia. With the global prevalence of smokers being around 30%, about 14% of all cases of Alzheimer's disease are attributable to smoking.<ref>Norton, Sam, et al. "Potential for primary prevention of Alzheimer's disease: an analysis of population-based data." ''The Lancet Neurology'' 13.8 (2014): 788-794.</ref> The evidence to the harmful effects on smoking on cognition are strong and show a dose-response effect.<ref name=":2">Grande, Giulia, Chengxuan Qiu, and Laura Fratiglioni. "Prevention of dementia in an ageing world: Evidence and biological rationale." ''Ageing Research Reviews'' (2020): 101045.</ref>
 
'''[[Mindfulness for our Patients|Mindfulness]]''' :many studies have linked mindfulness to cognitive and psychological improvements with older people who suffered  from MCI. <ref>Wong WP, Coles J, Chambers R, Wu DB, Hassed C. The effects of mindfulness on older adults with mild cognitive impairment. Journal of Alzheimer's disease reports. 2017 Jan 1;1(1):181-93.</ref>  <ref>Geiger PJ, Boggero IA, Brake CA, Caldera CA, Combs HL, Peters JR, Baer RA. Mindfulness-based interventions for older adults: a review of the effects on physical and emotional well-being. Mindfulness. 2016 Apr;7(2):296-307.</ref>
 
== Cognitive Impairment and Lifestyle-related Risk Factors ==
[[File:Dementia-care-02.jpg|alt=|right|frameless]]
 
Research has shown a relationship between the development of cognitive impairment and lifestyle-related risk factors that are shared with other [[Non-Communicable Diseases|noncommunicable diseases]]. These risk factors include:
* [[Physical Inactivity|Physical inactivity]]
* [[Obesity]]
* Unbalanced diet
* Unbalanced diet
* Tobacco use
* Tobacco use
* Harmful use of alcohol
* Harmful use of alcohol
* Diabetes Mellitus
* [[Diabetes Mellitus Type 2|Diabetes Mellitus]]
* Mid-life hypertension
* Mid-life [[hypertension]]
*Cardiovascular pathology  
*Cardiovascular pathology  
[[File:Dementia-care-02.jpg|thumb]]
Other risk modifiable risk factors that are specific to dementia are:
Other risk modifiable risk factors that are specific to dementia are:
* Mid-life depression
* Mid-life depression
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* Social isolation
* Social isolation
* Cognitive inactivity
* Cognitive inactivity
In addition, non-modifiable genetic risk factors exist that increase the risk of developing dementia. It is worth noting that although a family history of dementia is common, the lifetime risk of dementia for relatives of most people with dementia is around 20%, compared with about 10% in the general population.<ref>Loy, Clement T., et al. "Genetics of dementia." ''The Lancet'' 383.9919 (2014): 828-840.</ref><!-- In a small proportion of families with a strong autosomal dominant family history of early-onset dementia a mutation in one of the dementia causing genes can be found. Each offspring has a 50:50 chance of inheriting the mutation. With this mutation comes a lifetime dementia risk of over 95%.[1]  -->
In addition, non-modifiable genetic risk factors exist that increase the risk of developing dementia. It is worth noting that although a family history of dementia is common, the lifetime risk of dementia for relatives of most people with dementia is around 20%, compared with about 10% in the general population.<ref>Loy, Clement T., et al. "Genetics of dementia." ''The Lancet'' 383.9919 (2014): 828-840.</ref>
 
== Economics ==
== Economics ==
The financial impact of dementia is significant, both for patients and their families and on a global scale. Families face cost of health and social care and reduction or loss of income. In 2015, the costs for direct medical, social care costs and costs of informal care for dementia were estimated at US$818 billion (1.1% of the GDP). The expected rise in costs for people with dementia worldwide is US$2 trillion by 2030. This total could undermine global social and economic development and overwhelm health and social services.<ref name=":0" />  
The financial impact of dementia is significant, both for patients and their families and on a global scale. Families face cost of health and social care and reduction or loss of income. In 2015, the costs for direct medical, social care costs and costs of informal care for dementia were estimated at US$818 billion (1.1% of the GDP). The expected rise in costs for people with dementia worldwide is US$2 trillion by 2030. This total could undermine global social and economic development and overwhelm health and social services.<ref name=":0" />  
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The most important measures are:
The most important measures are:
* Increasing physical activity
* Increasing physical activity
* Preventing and reducing obesity
* Preventing and reducing [[obesity]]
* Promotion of balanced and healthy diets
* Promotion of balanced and healthy diets
* Cessation of tobacco use and the harmful use of alcohol
* Cessation of tobacco use and the harmful use of alcohol
* Social engagement
* Social engagement
* Promotion of cognitively stimulating activities and learning
* Promotion of cognitively stimulating activities and learning
* Prevention and management of diabetes, hypertension and depression  
* Prevention and management of diabetes, hypertension and depression


== How can lifestyle-related risk factors contribute to the development of MCI and dementia? ==
== Role for physiotherapy in preventing dementia or MCI ==
[[File:Atherosclerosis diagram.png|thumb]]
When it comes to preventing not only dementia but also other non-communicable lifestyle-related diseases, there is an opportunity and expanding role for physiotherapists to influence the risk factors. Health promotion should be lifespan focussed and can be done through education, advice and exercise.<ref>Ries JD. A framework for rehabilitation for older adults living with dementia. Archives of Physiotherapy. 2022 Apr 1;12(1):9.</ref>
A healthy lifestyle of the whole lifespan considerably reduces the risk of dementia later in life.<ref>Winblad, Bengt, et al. "Defeating Alzheimer's disease and other dementias: a priority for European science and society." ''The Lancet Neurology'' 15.5 (2016): 455-532.</ref> Accumulating evidence indicates a close relation between the body and mind in the development of dementia. The brain is a highly vascularised organ and particularly vulnerable to impairment in blood flow and vascular pathology. Cardiovascular disease and dementia often occur in the same person, and share common risk factors.<ref>Grande, Giulia, et al. "Co-occurrence of cognitive impairment and physical frailty, and incidence of dementia: Systematic review and meta-analysis." ''Neuroscience & Biobehavioral Reviews'' (2019).</ref><ref>Qiu, Chengxuan, and Laura Fratiglioni. "A major role for cardiovascular burden in age-related cognitive decline." ''Nature Reviews Cardiology'' 12.5 (2015): 267.</ref><ref name=":2">Grande, Giulia, Chengxuan Qiu, and Laura Fratiglioni. "Prevention of dementia in an ageing world: Evidence and biological rationale." ''Ageing Research Reviews'' (2020): 101045.</ref> Cohort studies show that inter-cranial atherosclerosis increases the chance of dementia, independent of Alzheimer's disease pathology and cerebral infarcts.<ref>Dolan, Hillary, et al. "Atherosclerosis, dementia, and Alzheimer disease in the Baltimore Longitudinal Study of Aging cohort." ''Annals of neurology'' 68.2 (2010): 231-240.</ref>  


The evidential support for a central role for systemic atherosclerosis in cognitive decline is growing and is suggested that even subclinical atherosclerotic pathology might be associated with poor vascular and brain health. In recent research, the presence of heart disease and heart failure has been associated with a 27% and 60% increased risk fo dementia.<ref>Wolters, Frank J., et al. "Coronary heart disease, heart failure, and the risk of dementia: a systematic review and meta-analysis." ''Alzheimer's & Dementia'' 14.11 (2018): 1493-1504.</ref> Although the etiologic role of atherosclerosis in Alzheimer's disease is still controversial, several studies have found correlations between carotid atherosclerosis and Alzheimer's disease.<ref>Hofman, Albert, et al. "Atherosclerosis, apolipoprotein E, and prevalence of dementia and Alzheimer's disease in the Rotterdam Study." ''The Lancet'' 349.9046 (1997): 151-154.</ref><ref>Yan, Z., et al. "Carotid stenosis and cognitive impairment amongst older Chinese adults living in a rural area: a population‐based study." ''European journal of neurology'' 23.1 (2016): 201-204.</ref> Nine out of ten studies included in a systematic review by Chang et al. linked asymptomatic carotid stenosis to cognitive dysfunction, which suggests that subclinical changes are at play in cognitive decline when atherosclerosis is present.<ref>Chang, Xue-Li, et al. "Association between asymptomatic carotid stenosis and cognitive function: a systematic review." ''Neuroscience & Biobehavioral Reviews'' 37.8 (2013): 1493-1499.</ref>
The physiotherapist could use the '''intervention mapping (IM) protocol''' to develop a programme and use [[Motivational Interviewing]] to empower the individual's motivation and self-commitment to behavioural change.


Sedentary behaviours increase psychological stress and are, due to disrupted homeostasis in blood pressure and glycemic levels, a greater vascular and metabolic burden.<ref>Panahi, Shirin, and Angelo Tremblay. "Sedentariness and health: Is sedentary behavior more than just physical inactivity?." ''Frontiers in public health'' 6 (2018): 258.</ref> Physical activity should be recommended to reduce the risk of cognitive decline.<ref name=":1" /><ref>WHO. "Risk reduction of cognitive decline and dementia: WHO Guidelines." (2019).</ref><ref>Ahlskog, J. Eric, et al. "Physical exercise as a preventive or disease-modifying treatment of dementia and brain aging." ''Mayo Clinic Proceedings''. Vol. 86. No. 9. Elsevier, 2011.</ref>
A randomised controlled study suggests that action observation (motor-related information available through the visual function) with [[gait]] training provides more significant benefits for gait and cognitive performances in the elderly with mild cognitive impairment<ref>Rojasavastera R, Bovonsunthonchai S, Hiengkaew V, Senanarong V. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7304276/ Action observation combined with gait training to improve gait and cognition in elderly with mild cognitive impairment A randomized controlled trial.] Dementia & Neuropsychologia. 2020 Jun;14(2):118-27.</ref>.


Research has shown that three types of exercise should be included in an individual's regular routine:
Systematic review<ref name=":3">Huang X, Zhao X, Li B, Cai Y, Zhang S, Yu F, Wan Q. [https://pubmed.ncbi.nlm.nih.gov/34051283/ Biomarkers for evaluating the effects of exercise interventions in patients with MCI or dementia: A systematic review and meta-analysis]. Experimental Gerontology. 2021 May 26:111424.</ref> studying the biomarkers related to cognition and exercises and cognitive-related effects triggered by exercises in patients with dementia and MCI revealed that:
* Sustained aerobic exercise
* exercise intervention could significantly reduce levels of LDL (metabolic marker) and IL-6 (inflammatory biomarker),
* Strength, weight or resistance training
* regular aerobic exercise could also decrease the levels of TNF-α (inflammatory biomarker)
* Flexibility and balance training
* Moderating effects of genotypes showed APOE ε4 non-carriers exhibiting significant improvements in peripheral BDNF (neurotrophic) levels.
Tobacco is the major risk factor for cancer, cardiovascular disease and dementia. With the global prevalence of smokers being around 30%, about 14% of all cases of Alzheimer's disease are attributable to smoking.<ref>Norton, Sam, et al. "Potential for primary prevention of Alzheimer's disease: an analysis of population-based data." ''The Lancet Neurology'' 13.8 (2014): 788-794.</ref> The evidence to the harmful effects on smoking on cognition are strong and show a dose-response effect.<ref name=":2" />  
However, no significant effect of exercise on Aβ and tau (main neuropathological hallmarks), BDNF, and oxidative stress biomarkers were observed, and more RCTs are required to  test the effects of exercise and provide strong evidence for future non-pharmaceutical therapy in patients with cognitive dysfunction.<ref name=":3" />


Alcoholic dementia and Wernicke-Korsakoff syndrome are well-known possible consequences of excessive and long-term alcohol consumption. There has been found a link between milder forms of MCI and dementia and alcohol abuse, which seems to cause neurotoxicity and neuroinflammation but also affects the brain directly by promoting nutritional deficiency.<ref>Day, Ed, et al. "Thiamine for Wernicke‐Korsakoff Syndrome in people at risk from alcohol abuse." ''Cochrane Database of Systematic Reviews'' 1 (2004).</ref> Interestingly, light-to-moderate alcohol consumption is linked with a reduced risk of cardiovascular morbidity and cognitive decline and dementia with respect to both alcohol abuse and a completely alcohol-free diet.<ref>Ruitenberg, Annemieke, et al. "Alcohol consumption and risk of dementia: the Rotterdam Study." ''The Lancet'' 359.9303 (2002): 281-286.</ref>
Focus on the benefits of a healthy lifestyle, and make it a goal for your patient to meet the recommended levels of physical activity:<ref name=":4" />
 
Finally, more and more evidence is emerging about the effect of diet on risk of cognitive impairment and dementia. Studies have pointed to the protective effect of some nutrients, including omega-3 polyunsaturated fatty acids and vitamins such as the B complex (vitamins B6, B12 and folate), antioxidants (vitamin A, C and E) and vitamin D.<ref>Hooshmand, Babak, et al. "Association of vitamin B12, folate, and sulfur amino acids with brain magnetic resonance imaging measures in older adults: a longitudinal population-based study." ''JAMA psychiatry'' 73.6 (2016): 606-613.</ref><ref>Rutjes, Anne WS, et al. "Vitamin and mineral supplementation for maintaining cognitive function in cognitively healthy people in mid and late life." ''Cochrane database of systematic reviews'' 12 (2018).</ref><ref>McCleery, Jenny, et al. "Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment." ''Cochrane Database of Systematic Reviews'' 11 (2018).</ref> Recently, research has focused on dietary patterns rather than single nutrients and their association with cognition and evidence suggests that healthy dietary patterns such as the Mediterranean diet is associated with less cognitive decline and a lower risk of dementia or Alzheimer's disease.<ref>Prinelli, Federica, et al. "Specific nutrient patterns are associated with higher structural brain integrity in dementia-free older adults." ''NeuroImage'' 199 (2019): 281-288.</ref><ref>Shakersain, Behnaz, et al. "Prudent diet may attenuate the adverse effects of Western diet on cognitive decline." ''Alzheimer's & Dementia'' 12.2 (2016): 100-109.</ref><ref>Sindi, Shireen, et al. "Healthy dietary changes in midlife are associated with reduced dementia risk later in life." ''Nutrients'' 10.11 (2018): 1649.</ref> Dietary patterns rich in red meat and sugar-rich foods have been associated with higher mortality. According to research on diet patterns, some key ingredients that are associated with longevity and better cardiometabolic and cognitive health can be identified. These include a high intake of fruit, vegetables, fish, (whole) grains, legumes/ pulses and potatoes.<ref>Kiefte-de Jong, Jessica C., John C. Mathers, and Oscar H. Franco. "Nutrition and healthy ageing: the key ingredients." ''Proceedings of the Nutrition Society'' 73.2 (2014): 249-259.</ref> It should be noted however, that the majority of findings with regard to the Mediterranean diet provide evidence for a correlation, and not a cause-and-effect relation.<ref>van de Rest, Ondine, et al. "Dietary patterns, cognitive decline, and dementia: a systematic review." ''Advances in nutrition'' 6.2 (2015): 154-168.</ref><ref>Petersson, Sara Danuta, and Elena Philippou. "Mediterranean diet, cognitive function, and dementia: a systematic review of the evidence." ''Advances in Nutrition'' 7.5 (2016): 889-904.</ref>
 
== Role for physiotherapy in preventing dementia or MCI ==
When it comes to preventing not only dementia but also other non-communicable lifestyle-related diseases, there is an opportunity and expanding role for physiotherapists to influence the risk factors. Health promotion should be lifespan focussed and can be done through education, advice and exercise. The physiotherapist could use the intervention mapping (IM) protocol to develop a programme and use [[Motivational Interviewing]] to empower the individual's motivation and self-commitment to behavioural change.
 
Focus on the benefits of a healthy lifestyle, and make it a goal for your patient to meet the recommended levels of physical activity:
* Adults aged 18–64 should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity.
* Adults aged 18–64 should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity.
* Aerobic activity should be performed in bouts of at least 10 minutes duration.
* Aerobic activity should be performed in bouts of at least 10 minutes duration.
* For additional health benefits, adults should increase their moderate-intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous-intensity aerobic physical activity per week, or an equivalent combination of moderate- and vigorous-intensity activity.
* For additional health benefits, adults should increase their moderate-intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous-intensity aerobic physical activity per week, or an equivalent combination of moderate- and vigorous-intensity activity.
* Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.<ref>World Health Organization. "Information sheet: Global recommendations on physical activity for health 5-17 years old." ''Geneva: World Health Organization'' (2011).</ref>
* Muscle-strengthening activities should be done involving '''major muscle groups on 2 or more days a week'''.<ref name=":4">World Health Organization. "Information sheet: Global recommendations on physical activity for health 5-17 years old." ''Geneva: World Health Organization'' (2011).</ref>
 
=== Non-Invasive brain Stimulation for Preventing dementia or MCI ===
Non-invasive brain stimulation (NIBS) such as transcranial direct current stimulation,tDCS and transcranial alternating current stimulation, tDCS, has been proven to beneficial in improving cognition.<ref>Pini L, Manenti R, Cotelli M, Pizzini FB, Frisoni GB, Pievani M. Non-invasive brain stimulation in dementia: a complex network story. Neurodegenerative Diseases. 2018;18(5-6):281-301.</ref>  Recently evidence suggests that anodal type of transcranial direct current stimulation to dorsolateral prefrontal cortex and left inferior [[Frontal Lobe|frontal cortex]] improves cognition in patient with MCI. Therefore, NIBS may be considered among group of patient with MCI.<ref>Fileccia E, Di Stasi V, Poda R, Rizzo G, Stanzani-Maserati M, Oppi F, Avoni P, Capellari S, Liguori R. Effects on cognition of 20-day anodal transcranial direct current stimulation over the left dorsolateral prefrontal cortex in patients affected by mild cognitive impairment: a case-control study. Neurological Sciences. 2019 Sep;40(9):1865-72.</ref><ref>Meinzer M, Lindenberg R, Phan MT, Ulm L, Volk C, Flöel A. Transcranial direct current stimulation in mild cognitive impairment: behavioral effects and neural mechanisms. Alzheimer's & Dementia. 2015 Sep 1;11(9):1032-40.</ref>


== Conclusion ==
== Conclusion ==
The vast majority of research tend to support that physical activity is a promising intervention for the prevention and non-pharmacological treatment of dementia. Results vary according to the particular characteristics as type, intensity, frequency and duration.<ref>Kouloutbani, K., K. Karteroliotis, and Antonis Politis. "The effect of physical activity on dementia." ''Psychiatrike= Psychiatriki'' 30.2 (2019): 142-155.</ref> Preventing stroke, treating heart diseases, and reducing vascular risk factor burden would therefore represent a powerful strategy to reduce the burden of dementia worldwide.<ref>Hachinski, Vladimir, et al. "Preventing dementia by preventing stroke: The Berlin Manifesto." ''Alzheimer's & Dementia'' 15.7 (2019): 961-984.</ref> All preventive strategies taken in dementia prevention need to be implemented in a life-course approach, such as control of hypertension, obesity and other modifiable risk factors.<ref>Kivipelto, Miia, Francesca Mangialasche, and Tiia Ngandu. "Lifestyle interventions to prevent cognitive impairment, dementia and Alzheimer disease." ''Nature Reviews Neurology'' 14.11 (2018): 653-666.</ref> The results are stronger when these factors are managed in midlife, compared to later life. International guidelines on physical activity are evidence-based to reduce the negative consequences of a unhealthy lifestyle and following these guidelines is recommended.  
The vast majority of research tend to support that physical activity is a promising intervention for the prevention and non-pharmacological treatment of dementia. Results vary according to the particular characteristics as type, intensity, frequency and duration.<ref>Kouloutbani, K., K. Karteroliotis, and Antonis Politis. "The effect of physical activity on dementia." ''Psychiatrike= Psychiatriki'' 30.2 (2019): 142-155.</ref>
 
* Preventing [[stroke]], treating heart diseases, and reducing vascular risk factor burden would therefore represent a powerful strategy to reduce the burden of dementia worldwide.<ref>Hachinski, Vladimir, et al. "Preventing dementia by preventing stroke: The Berlin Manifesto." ''Alzheimer's & Dementia'' 15.7 (2019): 961-984.</ref>
* All preventive strategies taken in dementia prevention need to be implemented in a life-course approach, such as control of hypertension, obesity and other modifiable risk factors.<ref>Kivipelto, Miia, Francesca Mangialasche, and Tiia Ngandu. "Lifestyle interventions to prevent cognitive impairment, dementia and Alzheimer disease." ''Nature Reviews Neurology'' 14.11 (2018): 653-666.</ref> The results are stronger when these factors are managed in midlife, compared to later life.
* International guidelines on physical activity are evidence-based to reduce the negative consequences of a unhealthy lifestyle and following these guidelines is recommended.  


An important take-home message, based on various studies, is that it is never too late to start prevention. Preventive interventions that improve the risk profile even of older individuals can delay the onset of MCI and dementia.<ref name=":2" />
'''An important take-home message, based on various studies, is that it is never too late to start prevention. Preventive interventions that improve the risk profile even of older individuals can delay the onset of MCI and dementia'''.<ref name=":2" />


== Resources ==
== Resources ==
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[[Category:Dementia]]
[[Category:Global Health]]
[[Category:Health Promotion]]
[[Category:Older People/Geriatrics]]
[[Category:Older People/Geriatrics - Interventions]]
[[Category:Interventions]]

Latest revision as of 16:41, 28 April 2023

Original Editor - Marleen Moll Top Contributors - Marleen Moll, Lucinda hampton, Vidya Acharya, Shaimaa Eldib, Kim Jackson, Tolulope Adeniji, Lauren Lopez and Aminat Abolade

Introduction[edit | edit source]

The amount of people suffering from mild cognitive impairment (MCI) or any type of dementia has been constantly on the rise. Around 50 million people suffer from dementia worldwide, with 10 million new cases every year. Although age is the strongest known risk factor for dementia, it is not a normal and inevitable consequence of aging[1].

The term dementia includes several diseases that are mostly progressive and affect the memory, other cognitive abilities and behaviour. The disease interferes significantly with one's ability to maintain activities of daily living.

  • MCI is generally defined as significant memory loss without the loss of other cognitive functions. People with MCI have more memory problems than would be expected from someone at a similar age. People with MCI are able to function independently and do not show other signs of dementia, such as impaired reasoning or judgment[2].
  • Dementia describes a collection of symptoms that are caused by disorders affecting the brain. It is not one specific disease. Dementia affects thinking, behaviour and the ability to perform everyday tasks. Brain function is affected enough to interfere with the person’s normal social or working life.[2]

While there's currently no treatment that can prevent or cure dementia, researchers have identified some factors that may help protect you from cognitive decline.

Protection factors from Cognitive Decline[edit | edit source]

Exercise - has many health benefits. It helps prevent heart disease and type 2 diabetes; lowers the risk for high blood pressure, colon cancer, and breast cancer; and helps relieve insomnia, anxiety, and depression. In addition, it may help ward off cognitive decline and dementia.

  • Some studies have shown that engaging in a program of regular exercise improved cognitive function in people who already had memory problems.[3][4]
  • Exercise may be particularly advantageous for people who carry the APOE4 gene variant, which makes people more susceptible to Alzheimer's.
  • Sedentary behaviours increase psychological stress and are a greater vascular and metabolic burden.[5]
Healthy food 2.jpg

A Mediterranean-style diet - Emphasizes fruits, vegetables, whole grains, beans, nuts and seeds, and olive oil, and includes moderate amounts of fish, poultry, and dairy products, while limiting red meat. This diet has long been recognized as promoting better cardiovascular health ,lowering the risk of certain cancers, and may protect against cognitive  decline.

  • Studies point to the protective effect of eg omega-3 polyunsaturated fatty acids and vitamins B6, B12 and folate, antioxidants (vitamin A, C and E) and vitamin D.[6][7][8]

Alcohol

  • Some older studies suggest that people who consume an average of one alcoholic beverage per day may have a lower risk of dementia. However, experts do not recommend drinking alcohol to prevent cognitive decline. If you enjoy an occasional alcoholic beverage, you should limit your consumption to no more one drink per day.
  • In the JAMA study, heavy drinkers—defined as more than four drinks per day or 14 per week for men and more than three drinks per day or seven per week for women—had a 22% higher Alzheimer's risk than the nondrinkers.
  • Alcoholic dementia and Wernicke-Korsakoff syndrome are well-known possible consequences of excessive and long-term alcohol consumption.
  • There is link between milder forms of MCI and dementia and alcohol abuse, which seems to cause neurotoxicity and neuroinflammation but also affects the brain directly by promoting nutritional deficiency.[9]
Sleep baby.jpg

Sleep - Getting consistent, good-quality sleep improves overall health and may prevent cognitive decline. We need a certain amount of regular sleep for a variety of essential functions, many of them in the brain. People who regularly sleep less than the recommended seven to eight hours a night score lower on tests of mental function, possibly because learning and memories are consolidated during sleep.

Mental stimulation : Education level is less important in maintaining a healthy brain than the habit of staying mentally active as you age.[10][11]

Social contacts - Social interaction can have profound effects on your health and longevity. Strong social connections may be as important as physical activity and a healthy diet. Social activities require you to engage several important mental processes, including attention and memory, which can bolster cognition. Frequent engagement helps strengthen neural networks, slowing normal age-related declines. It may also help strengthen cognitive reserve, which can delay the onset of dementia[12].

Reduce cardiovascular risk factors - Recent research shows the presence of heart disease and heart failure has been associated with a 27% and 60% increased risk for dementia. The etiologic role of atherosclerosis in Alzheimer's disease is still controversial, but several studies have found correlations between carotid atherosclerosis and Alzheimer's disease. A systematic review by Chang et al, linked asymptomatic carotid stenosis to cognitive dysfunction, suggesting that subclinical changes are involved in cognitive decline when atherosclerosis is present.[13][14][15][16]

Smoking - Tobacco is the major risk factor for cancer, cardiovascular disease and dementia. With the global prevalence of smokers being around 30%, about 14% of all cases of Alzheimer's disease are attributable to smoking.[17] The evidence to the harmful effects on smoking on cognition are strong and show a dose-response effect.[18]

Mindfulness :many studies have linked mindfulness to cognitive and psychological improvements with older people who suffered from MCI. [19] [20]

Cognitive Impairment and Lifestyle-related Risk Factors[edit | edit source]

Research has shown a relationship between the development of cognitive impairment and lifestyle-related risk factors that are shared with other noncommunicable diseases. These risk factors include:

Other risk modifiable risk factors that are specific to dementia are:

  • Mid-life depression
  • Low educational attainment
  • Social isolation
  • Cognitive inactivity

In addition, non-modifiable genetic risk factors exist that increase the risk of developing dementia. It is worth noting that although a family history of dementia is common, the lifetime risk of dementia for relatives of most people with dementia is around 20%, compared with about 10% in the general population.[21]

Economics[edit | edit source]

The financial impact of dementia is significant, both for patients and their families and on a global scale. Families face cost of health and social care and reduction or loss of income. In 2015, the costs for direct medical, social care costs and costs of informal care for dementia were estimated at US$818 billion (1.1% of the GDP). The expected rise in costs for people with dementia worldwide is US$2 trillion by 2030. This total could undermine global social and economic development and overwhelm health and social services.[1]

Prevention[edit | edit source]

The World Health Organization wrote the global action plan on the public response to dementia, in which there lies a big role for the prevention of dementia. Their vision is as follows:

"The vision of the global action plan on the public health response to dementia is a world in which dementia is prevented and people with dementia and their carers live well and receive the care and support they need to fulfil their potential with dignity, respect, autonomy and equality." - WHO, Global Action Plan on the Public Health Response to Dementia 2017-2025 (2017)

As mentioned before, there is a relationship between dementia, MCI and noncommunicable disease and lifestyle-related risk factors. By reducing the level of exposure of both individuals and populations to the modifiable risk factors (beginning in childhood), the capacity to make healthier choices can be strengthened.

The most important measures are:

  • Increasing physical activity
  • Preventing and reducing obesity
  • Promotion of balanced and healthy diets
  • Cessation of tobacco use and the harmful use of alcohol
  • Social engagement
  • Promotion of cognitively stimulating activities and learning
  • Prevention and management of diabetes, hypertension and depression

Role for physiotherapy in preventing dementia or MCI[edit | edit source]

When it comes to preventing not only dementia but also other non-communicable lifestyle-related diseases, there is an opportunity and expanding role for physiotherapists to influence the risk factors. Health promotion should be lifespan focussed and can be done through education, advice and exercise.[22]

The physiotherapist could use the intervention mapping (IM) protocol to develop a programme and use Motivational Interviewing to empower the individual's motivation and self-commitment to behavioural change.

A randomised controlled study suggests that action observation (motor-related information available through the visual function) with gait training provides more significant benefits for gait and cognitive performances in the elderly with mild cognitive impairment[23].

Systematic review[24] studying the biomarkers related to cognition and exercises and cognitive-related effects triggered by exercises in patients with dementia and MCI revealed that:

  • exercise intervention could significantly reduce levels of LDL (metabolic marker) and IL-6 (inflammatory biomarker),
  • regular aerobic exercise could also decrease the levels of TNF-α (inflammatory biomarker)
  • Moderating effects of genotypes showed APOE ε4 non-carriers exhibiting significant improvements in peripheral BDNF (neurotrophic) levels.

However, no significant effect of exercise on Aβ and tau (main neuropathological hallmarks), BDNF, and oxidative stress biomarkers were observed, and more RCTs are required to test the effects of exercise and provide strong evidence for future non-pharmaceutical therapy in patients with cognitive dysfunction.[24]

Focus on the benefits of a healthy lifestyle, and make it a goal for your patient to meet the recommended levels of physical activity:[25]

  • Adults aged 18–64 should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity.
  • Aerobic activity should be performed in bouts of at least 10 minutes duration.
  • For additional health benefits, adults should increase their moderate-intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous-intensity aerobic physical activity per week, or an equivalent combination of moderate- and vigorous-intensity activity.
  • Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.[25]

Non-Invasive brain Stimulation for Preventing dementia or MCI[edit | edit source]

Non-invasive brain stimulation (NIBS) such as transcranial direct current stimulation,tDCS and transcranial alternating current stimulation, tDCS, has been proven to beneficial in improving cognition.[26] Recently evidence suggests that anodal type of transcranial direct current stimulation to dorsolateral prefrontal cortex and left inferior frontal cortex improves cognition in patient with MCI. Therefore, NIBS may be considered among group of patient with MCI.[27][28]

Conclusion[edit | edit source]

The vast majority of research tend to support that physical activity is a promising intervention for the prevention and non-pharmacological treatment of dementia. Results vary according to the particular characteristics as type, intensity, frequency and duration.[29]

  • Preventing stroke, treating heart diseases, and reducing vascular risk factor burden would therefore represent a powerful strategy to reduce the burden of dementia worldwide.[30]
  • All preventive strategies taken in dementia prevention need to be implemented in a life-course approach, such as control of hypertension, obesity and other modifiable risk factors.[31] The results are stronger when these factors are managed in midlife, compared to later life.
  • International guidelines on physical activity are evidence-based to reduce the negative consequences of a unhealthy lifestyle and following these guidelines is recommended.

An important take-home message, based on various studies, is that it is never too late to start prevention. Preventive interventions that improve the risk profile even of older individuals can delay the onset of MCI and dementia.[18]

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 Prince M, Wimo A, Guerchet M, Ali GC, Wu Yutzu, Prina M. World Alzheimer Report 2015. The global impact of dementia: an analysis of prevalence, incidence, cost and trends. London: Alzheimer’s Disease International; 2015
  2. ↑ 2.0 2.1 Dementia Australia MCI Available: https://www.dementia.org.au/about-dementia-and-memory-loss/about-dementia/memory-loss/mild-cognitive-impairment (accessed 21.9.2021)
  3. ↑ Liu IT, Lee WJ, Lin SY, Chang ST, Kao CL, Cheng YY. Therapeutic effects of exercise training on elderly patients with dementia: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2020 May 1;101(5):762-9.
  4. ↑ Hilfiker R. Exercise for older adults with mental health problems. InPrimary Care Mental Health in Older People 2019 (pp. 127-143). Springer, Cham.
  5. ↑ Panahi, Shirin, and Angelo Tremblay. "Sedentariness and health: Is sedentary behavior more than just physical inactivity?." Frontiers in public health 6 (2018): 258.
  6. ↑ Hooshmand, Babak, et al. "Association of vitamin B12, folate, and sulfur amino acids with brain magnetic resonance imaging measures in older adults: a longitudinal population-based study." JAMA psychiatry 73.6 (2016): 606-613.
  7. ↑ Rutjes, Anne WS, et al. "Vitamin and mineral supplementation for maintaining cognitive function in cognitively healthy people in mid and late life." Cochrane database of systematic reviews 12 (2018).
  8. ↑ McCleery, Jenny, et al. "Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment." Cochrane Database of Systematic Reviews 11 (2018).
  9. ↑ Day, Ed, et al. "Thiamine for Wernicke‐Korsakoff Syndrome in people at risk from alcohol abuse." Cochrane Database of Systematic Reviews 1 (2004).
  10. ↑ Lövdén M, Fratiglioni L, Glymour MM, Lindenberger U, Tucker-Drob EM. Education and cognitive functioning across the life span. Psychological Science in the Public Interest. 2020 Aug;21(1):6-41.
  11. ↑ Peeters G, Kenny RA, Lawlor B. Late life education and cognitive function in older adults. International Journal of Geriatric Psychiatry. 2020 Jun;35(6):633-9.
  12. ↑ Havard health Protecting against cognitive decline Available: https://www.health.harvard.edu/mind-and-mood/protecting-against-cognitive-decline (accessed 21.9.2021)
  13. ↑ Wolters, Frank J., et al. "Coronary heart disease, heart failure, and the risk of dementia: a systematic review and meta-analysis." Alzheimer's & Dementia 14.11 (2018): 1493-1504.
  14. ↑ Yan, Z., et al. "Carotid stenosis and cognitive impairment amongst older Chinese adults living in a rural area: a population‐based study." European journal of neurology 23.1 (2016): 201-204.
  15. ↑ Chang, Xue-Li, et al. "Association between asymptomatic carotid stenosis and cognitive function: a systematic review." Neuroscience & Biobehavioral Reviews 37.8 (2013): 1493-1499.
  16. ↑ Hofman, Albert, et al. "Atherosclerosis, apolipoprotein E, and prevalence of dementia and Alzheimer's disease in the Rotterdam Study." The Lancet 349.9046 (1997): 151-154.
  17. ↑ Norton, Sam, et al. "Potential for primary prevention of Alzheimer's disease: an analysis of population-based data." The Lancet Neurology 13.8 (2014): 788-794.
  18. ↑ 18.0 18.1 Grande, Giulia, Chengxuan Qiu, and Laura Fratiglioni. "Prevention of dementia in an ageing world: Evidence and biological rationale." Ageing Research Reviews (2020): 101045.
  19. ↑ Wong WP, Coles J, Chambers R, Wu DB, Hassed C. The effects of mindfulness on older adults with mild cognitive impairment. Journal of Alzheimer's disease reports. 2017 Jan 1;1(1):181-93.
  20. ↑ Geiger PJ, Boggero IA, Brake CA, Caldera CA, Combs HL, Peters JR, Baer RA. Mindfulness-based interventions for older adults: a review of the effects on physical and emotional well-being. Mindfulness. 2016 Apr;7(2):296-307.
  21. ↑ Loy, Clement T., et al. "Genetics of dementia." The Lancet 383.9919 (2014): 828-840.
  22. ↑ Ries JD. A framework for rehabilitation for older adults living with dementia. Archives of Physiotherapy. 2022 Apr 1;12(1):9.
  23. ↑ Rojasavastera R, Bovonsunthonchai S, Hiengkaew V, Senanarong V. Action observation combined with gait training to improve gait and cognition in elderly with mild cognitive impairment A randomized controlled trial. Dementia & Neuropsychologia. 2020 Jun;14(2):118-27.
  24. ↑ 24.0 24.1 Huang X, Zhao X, Li B, Cai Y, Zhang S, Yu F, Wan Q. Biomarkers for evaluating the effects of exercise interventions in patients with MCI or dementia: A systematic review and meta-analysis. Experimental Gerontology. 2021 May 26:111424.
  25. ↑ 25.0 25.1 World Health Organization. "Information sheet: Global recommendations on physical activity for health 5-17 years old." Geneva: World Health Organization (2011).
  26. ↑ Pini L, Manenti R, Cotelli M, Pizzini FB, Frisoni GB, Pievani M. Non-invasive brain stimulation in dementia: a complex network story. Neurodegenerative Diseases. 2018;18(5-6):281-301.
  27. ↑ Fileccia E, Di Stasi V, Poda R, Rizzo G, Stanzani-Maserati M, Oppi F, Avoni P, Capellari S, Liguori R. Effects on cognition of 20-day anodal transcranial direct current stimulation over the left dorsolateral prefrontal cortex in patients affected by mild cognitive impairment: a case-control study. Neurological Sciences. 2019 Sep;40(9):1865-72.
  28. ↑ Meinzer M, Lindenberg R, Phan MT, Ulm L, Volk C, Flöel A. Transcranial direct current stimulation in mild cognitive impairment: behavioral effects and neural mechanisms. Alzheimer's & Dementia. 2015 Sep 1;11(9):1032-40.
  29. ↑ Kouloutbani, K., K. Karteroliotis, and Antonis Politis. "The effect of physical activity on dementia." Psychiatrike= Psychiatriki 30.2 (2019): 142-155.
  30. ↑ Hachinski, Vladimir, et al. "Preventing dementia by preventing stroke: The Berlin Manifesto." Alzheimer's & Dementia 15.7 (2019): 961-984.
  31. ↑ Kivipelto, Miia, Francesca Mangialasche, and Tiia Ngandu. "Lifestyle interventions to prevent cognitive impairment, dementia and Alzheimer disease." Nature Reviews Neurology 14.11 (2018): 653-666.
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