Jump to Transcript

In this episode, Matt & Lauren have the unique opportunity to talk with Dr. Helen C. Kales, a geriatric psychiatrist and health services researcher who has participated in the previous Lancet Commissions on Dementia Prevention, Intervention and Care – including the most recent one released in 2024. Dr. Kales discusses how the commission puts together all the evidence to make recommendations that can play a crucial role in dementia prevention. Dr. Kales is the Chair of the Department of Psychiatry and Behavioral Sciences and Joe P. Tupin Professor of Psychiatry at the University of California at Davis and has dedicated much of her career to improving the lives of patients living with dementia.   

More resources

Helen C. Kales, MD Faculty Profile 

2024 Lancet Commission: Dementia prevention, intervention, and care: 2024 report of the Lancet Standing Commission 

Transcript

Lauren Gerlach:

Welcome to another episode of Minding Memory. Today we're diving into the topic of dementia prevention throughout the lifespan. While there are now new and emerging disease-modifying therapies for Alzheimer's disease, the results of trials from available therapies have been relatively modest and slowing progression of the disease and can come with some very serious side effects. At the same time, there's growing evidence that potentially modifiable risk factors in early and midlife can have a significant impact on dementia incidence, making prevention even more important than ever. The Lancet Commission on Dementia Prevention, Intervention and Care was originally convened in 2017 to review the available evidence to produce recommendations on how to best manage or even prevent the dementia epidemic.

This report lists potentially modifiable risk factors for dementia and has become what most consider the go-to source for information on dementia risk factors. There have been two subsequent iterations of the commission published in 2020 and 2024. According to the most recent 2024 Lancet Commission on Dementia Prevention, Intervention and Care, it's estimated that up to 45% of dementia cases are potentially preventable, highlighting how modifiable risk factors can play a crucial role in dementia prevention. But what does it take to pull together all of this evidence and make these recommendations? Today we have the unique opportunity to talk with someone who's participated in each of the Lancet Commissions.

Matt Davis:

I'm Matt Davis.

Lauren Gerlach:

I'm Lauren Gerlach.

Matt Davis:

And you're listening to Minding Memory.

Lauren Gerlach:

Today we're excited to be joined by an expert in the field, Dr. Helen Kales. Dr. Kales is a geriatric psychiatrist and health services researcher. She's a professor and chair of psychiatry at UC Davis and has dedicated much of her career to improving the lives of patients living with dementia. Dr. Kales also served on the 2017, 2020 and 2024 Lancet Commissions, and we're honored to have her with us today to discuss the latest findings. Dr. Kales, welcome to Minding Memory.

Helen Kales:

Thank you, Lauren. It's a pleasure to be here and to talk about the Lancet panel.

Lauren Gerlach:

Wonderful. So to start us off, Dr. Kales, can you give us a little background on the Lancet Commission itself? Why was it created and what were the main goals when it first started?

Helen Kales:

So I think the idea was that as the global burden of dementia continued to climb, we believed that there was really the need to consolidate emerging evidence about what could be done to prevent dementia as well as to manage it and potentially change the trajectory for both people living with dementia as well as their families and care partners. And I think that all of this was heightened by the idea that it would be better done with an international perspective. So bringing people from various countries and disciplines involved in dementia care together in one place to really hash through the evidence and talk about what were the really most salient findings at the time.

Lauren Gerlach:

Could you tell us a little bit about the composition of the team? So what clinical and research areas are represented?

Helen Kales:

So I think the group in England, which they're from University College London or UCL, where all of the commissions have been held, they're largely composed of what are called old age psychiatrists in the UK, and that would be known as geriatric psychiatrists here. However, they also have brought in their colleagues from neurology, so people who would be cognitive neurologists or geriatric neurologists as well as folks from geriatric medicine. There have also been a number of people represented who do more biostatistical kind of work because that's been a huge part of analyzing all the data for these risk factors. And one of the things that's interesting from the 2017 to the 2024 group is there's really been an effort to include folks from what used to be called developing countries, but what we call in the 2024 paper as low income countries versus high income countries.

And I think those perspectives have been particularly critical. You reference the new potentially disease modifying treatments, and I think considering along with what you talked about, both risk and benefit, but also the ability of populations to either not benefit from those treatments because they're really hard to disseminate or they're really hard to incorporate as part of usual care. That becomes a big part of the consideration and emphasis that we've increasingly placed on health equity. So I think the process is meant to be inclusive and has gained steam in that area over the past seven years.

Lauren Gerlach:

And looking back to the original report in 2017, what were the main takeaways of the initial report that came out?

Helen Kales:

So that initial report really defined the original risk factors that were involved and really kind of advanced the idea of being ambitious about prevention. And if I can just backtrack a little to the process, one of the things that's really interesting is that each commissioner, as we're called, is assigned a topic pre-meeting and kind of does the research on that topic. For me, in that first meeting, it was really a focus on neuropsychiatric symptoms. In the last iteration, I focused on psychosis as a risk factor. And so we summarized that data and all the available evidence, and typically we're focusing on trials that are beyond a phase two trial or meta-analyses that are available.

And then we forward all of that to the group. That then is discussed over a two-day period in London. That really goes all day long as we talk through the evidence and there's a lot of vigorous debate. And then the UK team works with the biostatisticians to really look at the population attributable fraction of each risk factor and determine that. And then there's a lot of back and forth with the group over the succeeding months in the papers. So getting back to your question, which was, what was one of the big messages we hope to have with the original paper was we were thinking about heart disease and how studies like the Framingham study and other studies have really revolutionized.

We don't just focus now on caring for people with heart attacks, which is when that event happens. We focus a lot on, "How do we prevent that event? How do we manage people's blood pressure and manage their cholesterol?" And doing those things we've seen through big studies really changes those outcomes at a population level. And I even remember prior to leaving Michigan six years ago that Ken Langa and others were beginning to talk about how in developed countries or high-income countries, we were actually seeing the incidence of dementia coming down as a risk of prevention. So I think that idea was already in the zeitgeist.

So one of the things we thought about was how could we start a movement that really got people as excited about dementia prevention as we are about the prevention of cardiac events and stroke. And so that was...the headline was be ambitious about prevention. And the other thing I remember really well, it didn't come out in the paper, but it was part of the discussion, was we talked even about would there eventually be a public health campaign similar to... You guys are younger, but I was born in a 1965, and I can remember there were big campaigns about seatbelt use and many people did not use seatbelts in the late sixties and early seventies. And there really was this public health emphasis.

I mean now it's rare to see people driving without seat belts, but there was that sea change or paradigm shift through this public health campaign. And I think that was one of our thoughts is what if the world started to think that way and we could prevent? So getting back to the risk factors, I think many of them were ones that we know about, like depression, diabetes. But among the risk factors that were a little more surprising were hearing loss. I think this was one of the first big reports to really call that out, that hearing loss. And I can even remember a discussion around the table about are we sure this is right? Are we sure that these numbers are correct?

Because it really looked to be quite a big risk factor. So that's some of the salient things from the 2017 report and process.

Matt Davis:

So we just spent an episode actually talking about hearing loss and the link between that and dementia. I'm curious, the group must have talked a lot about causal mechanisms to make the declaration of something being modifiable. Is that something that the group spends a lot of time speaking about?

Helen Kales:

Yes, and that was a big discussion. Where did we think this signal was coming from and the evidence at the time? The other thing that these reports are intended to provoke is research. So we identify a risk factor. We hope that in the intervening years, people will then go, "I'm going to study that." And so at the time there had been a lot of research, I won't say a lot. There had been a significant amount of research identifying this as a potential risk factor, but not a lot of research on if you treat it, does it change the outcome? And so something really cool that we saw between the 2017 and 2020 reports was this burgeoning of intervention research that showed that if you intervene, it could make a difference.

And that's always the... Now we would say obviously, but you kind of have to show it for us to understand that. And yes, at that first 2017 meeting when we got beyond the shock of how big a risk factor it was, is this a brain mechanism? Is this related to social isolation? And I think our answer at the time based on the research was it's probably a little of all of it. It's a multifactorial risk factor, and yet one that is so potentially eminently modifiable if we can get people to use hearing aids. So to me, that's the beauty of the process that we saw all that hypothesis being then put into play in the research.

Matt Davis:

So you've been involved in all three reports. I'm just curious, what was it like to participate?

Helen Kales:

Oh my gosh, it is one of the most, I'm going to say fun experiences in my research career because-

Matt Davis:

I was not expecting that.

Helen Kales:

These really, really smart people gathered in a room, literally in a square kind of table. So you're kind of talking back and forth and you're talking about something that we're all passionate about all day. And there have been also so many collaborations that have come of it. I'm on two UK studies currently that have come out of working with people on this process, and one of them is called APPLE-Tree, which is such a lovely title and it's a multifactorial intervention for people with dementia. And so I think that sort of collaboration and camaraderie really becomes part of the day. And then as we've added new people in the group, something really memorable from the 2024 session was a group of the women investigators went out.

And we had people from the US, the UK, Africa, Japan. It was just an amazing interchange about what dementia care is like and how it's implemented in those settings and what it really takes to get people care. And so I use the word fun because I guess I'm a nerd and all of this is really fun, but also seeing people feel comfortable to express themselves. And at this meeting we had the 2024, a particularly heated discussion about the new treatments. And there were people, I will say mainly neurologists, that saw them as, "This is it, we've turned the corner, we're really here. We're showing that we can modify." And then there were a number of us who have concerns that these are modest effects.

That if we're clearing so much amyloid, why aren't we seeing bigger changes in cognition? And also we're very concerned about side effects and cost. And so I think those discussions became really intense, not unfriendly, but just differing perspectives on what these mean. The other thing we saw at the last meeting was an increasing number, kind of questioning the whole paradigm. We have been on this amyloid paradigm for a long time, and there were a few who began to say, should we be looking at other paradigms? And what about gut bacteria? But that didn't reach the level of... I think it might've been hinted at in the paper, but I'm hoping that that's something we see more of. Sort of like what are we looking at here?

And if again, we're clearing so much amyloid, but we're only seeing so much efficacy and cognitive outcomes, I suppose there are people who would say, "Well, it's too late at that point. You should have started earlier." But I think that as we begin to think about etiology, it's really important. I was just thinking about when I was in medical school, the predominant cause of ulcers, one of the predominant causes was thought to be stress. And we talked a lot about that. And again, chronic fatigue syndrome was looked at as stress. And now we know that a lot of GI pathology like ulcers is caused by bacteria.

And if you read about that investigator, he was laughed out of meetings at that time because it was thought to be so crazy. And I think as one of my colleagues likes to say in geriatric psychiatry, "It's so crazy, it just might be right." And so I think we need to broaden our horizons and this is the kind of meeting where we're able to do that and we're able to think about these things and kind of gain new perspectives. So I hope that answered your question.

Lauren Gerlach:

Absolutely. And we spoke to this some, but just wondering maybe just a few more details or your experience. So we've talked some about how the commission approach the enormous task of reviewing all of the available data. What does that actually look like? Are you assigned a huge number of articles? Are you given one topic over what span and then when you come together for the two-day meeting, what are really the priorities during that time?

Helen Kales:

So usually the assignment... So Gill Livingston is our leader. Every process needs a really great leader, and Gill is just incredible. She really had the foresight to bring all this together. I met her when I was on sabbatical in 2014 and spent time with her and other folks at UCL. And so I got to know her through that and she has implemented our DICE Approach in a number of trials, and so we've gotten to know each other. And so yes, usually there's a risk factor topic assigned, one spends a number of months researching that topic in depth and then providing the summary back to Gill and her team. Then when we get together as a group, those are then summarized.

There's PowerPoint presentations and we talk through all the data and usually each risk factor has a significant amount of discussion. And we really look at the data and we look again at not just the prevention aspects, but also as we've talked about the treatment aspects. So in this meeting there was probably a couple of hours of discussion about the new treatments and what they'll mean. And then there was additional data or information that came on from folks from international perspectives about people from lower income countries saying, "We're not going to have access to these agents." So it's not really going to be even in the cards for us to think about how we deploy them, because that's just not something that is going to happen in our countries.

And that's sobering to think about because we know that the prevalence of dementia is also increasing in those populations. And that's also how I believe it was in the 2020 paper, we added the risk factor of air pollution. That one came out as we were talking with folks from the developing countries about that becoming a bigger and bigger concern. One that we've largely mitigated here. My mom and dad were in LA and I was born there when I was... Until I was about six, we lived there. And my mom talks about how you used to not be able in Santa Monica or Brentwood to be able to see the mountains because there was so much air pollution. And now of course that's addressed, but in low income countries, that's still a big factor.

So that was one that came up. Post meeting, then that goes to the team and there's a lot of work done on the actual number crunching and looking at what would happen to cases over time and modeling if a certain risk factor was eliminated. And so that's where those numbers come from. The other thing that got generated in the 2017 report, which we just love, is the river diagram, which shows the risk factors from early to middle to late life. And I think I'm really struck by that because we often think as geriatric psychiatrists about what's happening in late life. But when you think to how someone's education can affect what happens to them in later life, that becomes...you know, we have to think about that as we think about policy.

So as they crunch through those numbers, then a lot of that data gets re-presented back to the commission usually by email. And then we all work on the document together and there's a lot of iterations that go back and forth, and they're long documents too, so it takes a lot of time. But there's a lot of richness in the comment section of those too, where people are weighing in, "I think we should say it like this, or we shouldn't say that, or we need to emphasize this." So it's really quite a group effort.

Matt Davis:

That figure is the main thing that comes to mind for me when I think of the report. Who came up with that? Was it a team effort or?

Helen Kales:

That I would say is the UCL team, but we all grew to love it so much that we just basically said it has to be included in every subsequent report because for me, it's like the river of life and it's so great to think about how we should really be working at each life stage to prevent dementia. That it's too late if we start thinking when somebody's in their sixties, but if we start thinking about this as something we work over a lifetime, and I think we'd all agree that having more education is something that's a good thing, and that really it relates to your cognitive reserve and the observation many of us have had that's borne out in research, that the more reserve you have, the more you can draw on and you don’t appear as cognitively impaired perhaps because you're able to have that information that you learned or those wells that you can go back to.

Matt Davis:

So in terms of the 2024 report, the most recent one, what would you say are the biggest updates or changes?

Helen Kales:

So the two new risk factors for dementia was one of the headlines and out of everything we looked at... So those were added to the 12 prior risk factors articulated in 2017 and 2020, and those are vision loss and high cholesterol. I don't think either of those are terribly surprising, and again, I think there's so much good evidence for our ability to mitigate those. I think the other big piece of this report that we sought to include was information on disease modifying treatments. And so we were careful with that to talk about, as Lauren mentioned in the beginning, the modest efficacy. That there is this modest efficacy over 18 months, but the notable side effects are of concern. And again, in those low-income countries that we have some resource implications as well as in our own country.

I mean, I know the VA, I believe Lauren has moved to include those I think in the formulary, but there's still a concern for that. I think I, as a provider, also think about there are people that I have a hard time getting in for a blood draw, for example, with certain medications. And so this is really a commitment from family members that you're going to be taking somebody back and forth for treatment for an extended period of time. And so again, I think that's really important to think about. I think we also in this last report really tried to underscore the risk factors with what some of the actions could be to mitigate those. So again, it's obvious, but for hearing loss, making hearing aids accessible and decreasing noise exposure, I worry a lot about this with...I see everybody, you guys are wearing headphones, but the headphones that go in your ears, we see those regularly. And I think as outside noise, if you're on a plane, is going, people will tend to have those at high volumes. And I sort of wonder about the impact that we all may face with hearing loss. We talked about basically a lot of the cardiovascular risk factors. I think the other thing we presented, which is a little bit of a bummer, is that there really doesn't seem to be a lot of evidence for exercise and as an intervention for neuropsychiatric symptoms. That's one of the things we would sort of hope to see with people being active. But as we looked at the evidence for that, we didn't see that.

But for neuropsychiatric or what they call internationally behavioral and psychological symptoms of dementia, there is evidence that tailored activity that was new in this report, that tailored activity. So what does that mean? A lot of times in care settings, people get one size fits all activity, like we're all going to do this craft or we're all going to answer some questions that are some form of remembrance therapy. And what Laura Gitlin's work has really shown is if you tailor activity to the likes of the person makes sense and their ability. That really helps neuropsychiatric symptoms more. The last thing I'll say that is coming to mind is there is a new medication that is approved by the FDA for agitation.

And so we briefly addressed that in this paper that it is a little bit controversial just because there were antipsychotics in the past, notably Risperidone that perhaps had more evidence for efficacy, but the composition of the FDA was different then and did not approve that for agitation. And so it appears that it was more of a cohort effect of the FDA and its approval process. The other thing about those trials that we noted was that many of the subjects that were in the trials were not from the U.S. Many of them were from Eastern Europe. And there's sort of a question about whether you can extrapolate from those populations to more diverse populations here.

The other thing is when you isolate that evidence for the drug, it did not appear as efficacious in the only US population. So we just added that part. As things become available, we see that as part of our duty to take in the evidence and speak on it.

Matt Davis:

We were particularly excited to see the vision get included because we actually had the chance to talk with Josh Ehrlich who was doing some work in that space early on, and it was kind of neat to see the progression of his work and the impact and land in the report. So I'm curious, so looking at the release of these reports, can we basically anticipate that there'll be an update every few years? Is that the plan?

Helen Kales:

Yes. So the Lancet has now made it what they call a standing commission. And what that means is that, as new evidence becomes available, we will reconvene every several years to review the data. And my hope is that we're just going to continue to see this burgeoning of research around prevention and around treatment. I think the other thing that excites me as a geriatric psychiatrist is there's always been this sense that everything was trying to not get this disease, but if you had it, oh no, you are through. And I think what we're starting to see is research looking at can we modify the trajectory of people that have dementia, particularly if we arrest some of these factors like hypertension or diabetes.

Can we keep people in a place where it looks more early in its course or moderate in its course and prevent them from getting to the severe stages? To me, that's sort the next frontier. Where can we look at interventions that may help us to keep people prolonged in a state that is less symptomatic? And I hope that's something that we'll be looking at in future iterations.

Lauren Gerlach:

So the updated report suggests that nearly half of dementia cases could be potentially prevented by eliminating these 14 risk factors. So diving a little deeper into the modifiable risk factors, which of these individual risk factors has the strongest association with dementia? And what should people really focus on in terms of most in terms of prevention? So if we could think about a top three, what would be the ones that are giving the most risk?

Helen Kales:

I think the top three are pretty evident from looking at that river diagram. So early in life, the less education. And I think that's one where we have to think of as a community for what we're prioritizing in terms of education. And sometimes it's hard to... A lot of our culture is more immediate, but if we think about what's going to affect something down the road, that seems really important. And then in midlife hearing loss, and I see that one as if you present people, everybody prizes their cognition. And so people may not want to wear hearing aids, but if you talk to them about, "Gosh, if this is something you don't do, what if this increases your risk? Here's the data on this." And I think that that feels pretty compelling to me to want to do.

And then in late life, I think social isolation emerges as a big one. And that's something we're thinking about in terms of during the pandemic, we certainly saw a huge heightened effect on people with dementia as even in nursing homes and assisted living facilities so as not to spread the pandemic, people were locked in their rooms, and that had a big effect on people. And so I think thinking about how we use technology too to mitigate some of the effects on social isolation, whether it's Zoom or FaceTime or other interventions where people can be in contact with other people, I think that's really important.

And thinking through how we, as a society, I'm always touched by those European societies where they say, "Oh, we've matched a young person who needs a home with an older person who might need help." And to me, those are such lovely as we think through Service Corps or things that people can do. It would seem to me that we as a country might be willing to look at this as sort of an epidemic of social isolation that can lead to really bad outcomes. And if we can just mitigate that a bit through some friendly visiting or some of these other ideas. That seems like pretty low-hanging fruit.

Lauren Gerlach:

So much of the US health care today is focused on prescribing medications. Thinking about both in your research hat and your clinician hat, how do we get doctors and clinicians to shift their focus towards these modifiable risk factors and really try to have a paradigm shift towards encouraging prevention and preventive care for dementia?

Helen Kales:

That's a great question. I think it gets back to that example about seatbelts. I think I would love to see some type of national effort, commercials. I can remember commercials from my youth about pollution and those... I mean, that had a huge effect on me as a kid. Don't litter. Littering is terrible. You don't do that. And so I would love to see that kind of campaign that we invested in to think about. I think it's really important, of course, to always be thinking about the cure, but I think thinking about prevention is sort of the next frontier, and thinking about how we encourage people to... What are some easy things that they can do in their day-to-day lives that would help to mitigate this epidemic?

I would love to see the Alzheimer's Association get behind something like that where we really think about it. And then I think also as geriatric psychiatrists, one of the things we need to do is communicate to people that treating depression effectively earlier in life, whether it's in young adulthood or later adulthood, that probably has some really important preventative effects as well. And so communicating that to people that we're not just, well just, it's very important. But treating depression itself is very important because it obviously impacts quality of life and your ability to function and be a family member and go to work. But if we also connect that to your cognitive abilities, I don't think people have totally gotten that message.

And so I think we as geriatric psychiatrists communicating that to our colleagues who do work earlier in life, I think that could be really important and also important for people to think about adherence to antidepressants. There's a lot of data that particularly in primary care, people are prescribed antidepressants and then don't necessarily adhere to them, but maybe if they understood that some of this could be connected to later cognition, I would think that would be really important.

Matt Davis:

So as a person who's thought a lot about risk factors, I'm curious what kinds of changes in health policy do you think are needed to reduce the incidence of dementia?

Helen Kales:

I think we have to start thinking a lot more as a collective. I know that Donovan Maust’s research, part of it was looking at how different states have implemented dementia policy, and every state kind of does it differently. I have had the opportunity to work with folks at University of Wisconsin. And one of the things they've done that I think is so effective is that they have created and trained over a hundred dementia care managers that fan across the state and basically function across the spheres of need and dementia. So we know they're more than medical need, but what about legal things? And if there's barriers in the way in terms of some of the things that become an issue with caregiving, the dementia care manager can basically function as sort of a hub and spoke for those patients with dementia.

And I think that would be a great national model to look at. And I know the GUIDE Process is intending to get at that with really enhancing what we can do with caregivers. But I would love to see... I don't think it really requires being in a medical setting. I actually think we should get out of medical settings and think about the needs across those spheres that people intersect with when they have dementia or they're a care partner for somebody with dementia. And so I would really love to see something like that. I actually think... I'm not a health economist, but I think if you did the research, I bet that having a dementia care manager would probably be, and I know they've done this at Indiana too, looking at different models of care…that having somebody who coordinates that care probably reduces unnecessary ED visits and hospitalizations, which also put people with dementia back. When somebody goes into the ED, it tends to be kind of a traumatic experience when somebody has dementia. So doing that kind of preventative work is probably not only cost saving, but also really good for that particular family and person with dementia. So I would love to see us focus more on dementia care managers. And of course then the next iteration would be, could those same folks or a related core of people also focus on prevention? And I think that would be sort of an interesting...we tend to leave these things up to associations like the Alzheimer's Association, but what if we made this more of a national effort because it really is going to fall on a lot of us in terms of our parents and our relatives. That cost of caregiving and what it does to the economy.

Lauren Gerlach:

After spending so much time reviewing the research and working on these reports, have any of these findings changed the way that you live your own life or perhaps the advice you give to your friends and family?

Helen Kales:

That's a great question. Definitely the hearing loss piece. So with my own parents, that's something I've worked really hard on. I actually pinned the river diagram with the hearing loss section circled after the 2017 report. Pinned it on my parents' mirror because my dad was so resistant to wearing hearing aids. And finally, as he thought through the cognitive piece, which made a difference to him, he began to wear hearing aids. And that was just really important for our family because my dad had always been a central part of our family. And to see him with hearing loss sitting at the end of the table watching the conversation go by and not being a part of it, you really see how one becomes isolated in their own world.

And so I think that's been really, really important to me. I think, as I said before, the treating depression part has really had an impact on me as these things come up with friends and family. Depression, people tend to think of it as, "Well, I don't want to take a medication," or "That's not natural." And so talking to people about antidepressants and the need to treat depression has been really important. I've been doing a lot more thinking. I think in this last report, we talked about sleep and how medications for sleep haven't really shown much effect in people with dementia, and we haven't been able to find many non-pharmacologic interventions that are shown to have effect.

So I've been thinking a lot more about sleep. I personally need a lot of sleep, and so I've been thinking lot about sleep. And so one of the things I've been thinking a lot about and teaming with somebody else on a grant is the impact of light on people with dementia and the ability of increasing natural light to entrain circadian rhythms and improve both depression and sleep. And I see that as such an outgrowth of this kind of work that this is, at least here in California, a very accessible resource. And it's been shown that older people do not get enough light. In fact, a lot of our facilities are built with the idea like, "Oh, we're going to make them sort of low light, zen-like, not too stimulating and spa-like."

And in fact, what happens is that they only get about a fifth of the natural light that they really need to entrain the circadian rhythms. So I think it's got me thinking more about prevention, and I love that aspect of being able to be proactive and not reactive. So I think those are, for me, some of the most important takeaways.

Matt Davis:

Light can be a problem in Michigan, by the way. We are going into several months where we're don't see the sun. I swear.

Helen Kales:

Well, have you ever noticed in Michigan that on a sunny day, all of a sudden your mood is better?

Matt Davis:

Totally.

Helen Kales:

It's one of those things that kind of teaches you whenever there is, I can see light streaming in your window. You need to get outside today, you need to take in some of that light. It's really important.

Lauren Gerlach:

So the most recent Lancet Commission includes an entire section on interventions for what we call neuropsychiatric or behavioral and psychological symptoms of dementia, which I know is your area of expertise. I was hoping you could share with us a little bit of some of the key findings and takeaways from that section.

Helen Kales:

I think some of the key takeaways were this was an update. In the first two papers, we did more on algorithms that were related to my work, looking at assessment and management of neuropsychiatric symptoms. And the DICE Approach was iterated with a number of symptoms. I think in this report we wanted to focus on any new evidence. And so we looked at the, as I mentioned, the multi-care coordinated, multi-component interventions, finding those were helpful, and also looking at tailored activity. I think the idea is now advanced that when people have dementia, we want them to live well with dementia. And so it's important to do that whether or not the studies are efficacious, but it looks like they are.

Again, no evidence for exercise, which was a bit disappointing. I think the focus for people with psychosis is to try to mitigate any risk factors that might be contributing to it, like hearing loss, visual loss, and then really careful use of antipsychotics. Of course, always looking at the ability to taper and discontinue because as we find symptoms are kind of a moving target and may not be there from one time period to another. So I think those would be the major new parts. I think as always we want to make sure we're looking at underlying causes, because if we just medicate a symptom like agitation, we may be missing what the underlying cause is, including pain or infection or some mismatch with a caregiver or something in the environment.

So again, I think that that meticulous management of underlying causes is always indicated.

Matt Davis:

So what would you say the key takeaways are from their report when it comes to researchers, clinicians, caregivers, and patients living with dementia?

Helen Kales:

I would say that dementia looks like it's eminently preventable, that we can prevent up to 50% of cases if you add all the risk factors together. And I think many of these are things we're already doing in medicine. So it's just a matter of incorporating the message along with preventing heart attack, for example. Controlling your blood pressure is good for preventing dementia. That's something people may not realize. And so incorporating that message and linking it also to things that people may not associate with dementia, like social isolation, I think is really important. That it's important to visit your loved one, not just of course for those emotional ties, but also for the cognitive stimulation it gives and again, prevention of dementia.

So I think incorporating these into our repertoire as healthcare providers is really important. And then with researchers, I think we would be hoping to continue just like with that example of the hearing loss in 2017 as a risk factor, to really see that evidence start to verge and that people start to look at these risk factors and start to come out with more data and more evidence. And then I think the other thing is paying attention to the health equity issues we've raised and how we may bridge the gaps with some of those low income countries. What are some of the things we can do to help as a global population mitigate the risk of dementia.

Because those populations can be relatively large, and if we start working on that now, we can prevent many more cases.

Lauren Gerlach:

Anything else you'd like our listeners to know?

Helen Kales:

Oh my gosh. I think you guys have asked so many great questions, and I appreciate the opportunity to talk through the process and kind of unpack it for people, because I think it may be sort of a black box of one of those things that you wonder, and I really appreciate the opportunity to kind of reminisce and talk through the process with you guys today.

Lauren Gerlach:

Well, Dr. Kales, thank you so much for joining us.

Helen Kales:

Thank you. It's been a pleasure. Enjoy talking with both of you.

Matt Davis:

If you enjoyed our discussion today, please consider subscribing to our podcast. Other episodes can be found on Apple Podcasts, Spotify, and SoundCloud. As well as directly from us at capra.med.umich.edu, where a full transcript of this episode is also available. On our website, you'll also find links to other resources we've created specifically for dementia research. Music and engineering for this podcast was provided by Dan Langa. More information is available at www.danlanga.com. Minding Memory is part of the Michigan Medicine podcast network. Find more shows at michiganmedicine.org/podcasts.

Support for this podcast comes from the National Institute on Aging at the National Institutes of Health, as well as the Institute for Healthcare Policy and Innovation at the University of Michigan. The views expressed in this podcast do not necessarily represent the views of the NIH or the University of Michigan. Thanks for joining us, and we'll be back soon.