This recent production from NICE – full title “Dementia, disability and frailty in later life – mid-life approaches to delay or prevent onset. NICE guidelines [ng16] http://www.nice.org.uk/guidance/ng16 – was published in October 2015. Dementia prevention is thus part of a job lot, along with disability and frailty.
Essentially this is a public health document, produced by a Public Health Advisory Committee (PHAC), devoid of diagnostic considerations. It seems to be based largely around “evidence statements” from the Cambridge Institute of Public Health, where Professor Carol Brayne has a long standing interest in these issues.1
There are in all 15 recommendations delivered in two subsections: promoting healthy lifestyles (8) and service organisation and delivery (7). The headline recommendations are summarised as: stop smoking; be more physically active; reduce alcohol consumption; adopt a healthy diet; and achieve and/or maintain a healthy weight. Nothing objectionable there, you may think; but read on!
Colleagues (and relatives) have asked me, based on the publicity in the media garnered by the document, whether we really do have to stop drinking alcohol altogether. Section 4.19 states that “PHAC heard expert testimony suggesting that, in light of current evidence and issues with the evidence base, the overall message should be that there is no safe level of alcohol consumption”. I presume that the “expert testimony” in question emanates from the erstwhile President of the RCP. The “issues with the evidence base” seem to revolve around the possibility that “non-drinkers”, who fare worse than moderate drinkers (the J-shaped curve), are in fact mostly ex-heavy drinkers, hence the reason that non-drinkers do badly. I’m not sure whether this is evidence or opinion: if the former, a few apposite references would not have gone amiss to try to convince the populace of what may be seen as a Draconian measure.
Some economic modelling has been undertaken, and this apparently “estimates that the biggest gains in reducing dementia come from interventions that raise physical activity levels from sedentary to low level activity” (Section 4.34). The key public health message, though hardly novel, may therefore be “More exercise!”.
As with previous NICE documents which I have read, this can hardly be described as a gripping encounter, unless you enjoy the deeply self-referential nature of NICE productions. It reads as a series of prescriptions and proscriptions for behaviour modification, an approach which might be described as managerial or “Skinnerian”, since it seems largely uninterested in the cognitive processes which cause people to fail to adopt, or indeed to do the opposite of, what promotes health.
The emphasis on dementia prevention is, of course, welcome (likewise the recommendations for further research). The failure of current therapeutic approaches suggests that prevention really may be a more appropriate strategy than cure, and the mid-life risk factors for dementia are well-recognised.2 But will this document have any impact, or deliver the desired effects? No one will ever know, because, as with all NICE documents which I have read, there is never any expectation or plan to measure impact.
[NB The opinions expressed here are those of the author, and do not necessarily represent those of his employers.]
- Lincoln P, Fenton K, Alessi C et al. The Blackfriars Consensus on brain health and dementia. Lancet 2014;383:1805-6.
- Kivipelto M, Ngandu T, Laatikainen T, Winblad B, Soininen H, Tuomilehto J. Risk score for the prediction of dementia in 20 years among middle aged people: a longitudinal, population-based study. Lancet Neurol 2006;5:735-41.