How has medicine changed in the past 20 years? A look at dementia, cancer care and chronic disease

The 21st century began with the first draft of the human genome, and with it, the promise of immense new powers to treat, prevent and cure disease.

In high-income countries like Australia, rates of heart disease were falling, and life expectancy was rising.

Over the past two decades, lots has changed about the factors that affect our health, wellbeing and how long (and well) we live.

So what do we know now that we didn’t then, and how far have we come?

As part of Radio National’s Big 20 series, Dr Norman Swan speaks to three leaders in their field to find out what’s happened in dementia research, cancer care and chronic disease over the last 20 years.

Chronic disease has been getting worse

Dr Norman Swan talks to Professor Chris Murray, director of the Institute of Health Metrics and Evaluation at the University of Washington.

Dr Swan: Take us back to the year 2000. What was the pattern of disease?

Professor Chris Murray: In the year 2000, right before the big push globally on reducing health problems in low income settings, we were pretty much nearing the peak of the HIV epidemic and, particularly in sub-Saharan Africa, we still had a very large number of deaths under age five — 12 million or so a year.

We hadn’t yet had the big efforts to control malaria. And many middle-income countries were right in that transition from a profile of disease burden dominated by infectious diseases and starting that shift towards cancer, heart disease, chronic kidney disease.

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In the high-income world — Australia, Europe, North America — the [disease burden] looked pretty similar. It was already heavily dominated by heart disease and cancer, chronic kidney disease, but there was less obesity back then, there was less diabetes, and we were still back in the heyday of heart disease coming down pretty rapidly.

Dr Swan: What has happened in the two decades since?

Professor Murray: We’ve seen really dramatic progress bringing down child death rates.

In a place like Niger in West Africa, the improvements are just spectacular. You’ve probably halved child death rates in that period … bringing [it] down below the 5 million mark because of antiretrovirals for HIV.

There has been real progress on controlling malaria because of bed-net programs. So just lots of progress racked up, until COVID, on a number of fronts in the low-income world.

Then at the other end of the spectrum in the high-income world, we’ve seen heart disease progress slow, and in some places reverse.

We’ve seen this steady rise of obesity and bringing with it diabetes, high blood sugar, bringing up blood pressure levels in some countries, despite all the therapies that exist for them.

In the middle-income world we’ve seen progress but we’ve seen the rise of ambient air pollution in the last two decades. It’s becoming a bigger and

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Do Leisure Activities Really Mitigate Dementia Risk?

Contrary to some previous research, new findings question whether leisure activities in middle age really do help mitigate subsequent dementia risk.

The study showed no association between taking part in more leisure activities at age 56 and the risk of dementia over the next 18 years. There was some benefit when leisure activity participation was assessed later in life.

“Of course there are many reasons to participate in leisure activities and this finding does not question the importance of keeping active for general health and well-being, but it does suggest that simply increasing leisure activity may not be a strategy for preventing dementia,” study investigator Andrew Sommerlad, PhD, from University College London, United Kingdom, said in a news release.

The study also showed that some people who were later diagnosed with dementia stopped participating in leisure activities years before they were diagnosed, suggesting that changes in the amount of leisure activity may be an early sign of dementia.

“Dementia appeared to be the cause, rather than consequence, of low levels of leisure activities,” Sommerlad told Medscape Medical News.

The study was published online October 28 in the journal Neurology

Still Beneficial

The study included 8280 adults (mean age, 56 years) who were followed for an average of 18 years as part of the Whitehall II study. Participants reported their leisure activities at the beginning of the study, 5 years later, and again 10 years later.

They were placed in low, medium, and high groups based on their levels of participation in leisure activities such as reading, listening to music, taking classes, participating in clubs, visiting friends/ relatives, playing cards or games, taking part in religious activities, and gardening.

During the study, 360 people developed dementia at a mean age of 76.2 years. The overall dementia incidence rate was 2.4 cases for 1000 person-years.

In fully adjusted Cox regression analyses, taking part in more leisure activities at an average age of 56 was not associated with a lower risk of dementia 18 years later (hazard ratio [HR] 0.92, 95% CI, 0.79 – 1.06). 

However, those with higher participation in leisure activities later in life, at a mean age of 66, were less likely to develop dementia over the next 8 years than those with lower participation (HR, 0.82; 95% CI, 0.69 – 0.98).

In addition, a decline in leisure activity during the study was associated with an increased risk of dementia (HR, 1.38; 95% CI, 1.20 – 1.59). 

Of the 1159 people whose activity decreased during the study, 53 (5%) developed dementia, compared with 17 (2%) of 820 people who maintained their leisure activity level.

“More research is needed to confirm these results, but we know that early changes in the brain can start decades before any symptoms emerge,” Sommerlad said in the news release.

“It’s plausible that people may slow down their activity level up to 10 years before dementia is actually diagnosed, due to subtle changes and symptoms that are not yet recognized,” he added.

“There is no

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Staying Active as You Age Not a Guarantee Against Dementia | Health News

By Dennis Thompson HealthDay Reporter

(HealthDay)

THURSDAY, Oct. 29, 2020 (HealthDay News) — Experts in healthy aging often cite the importance of leisure activities — hanging out with friends, playing games, taking classes — in maintaining your brain health as you grow older.

But a new study calls into question whether those enjoyable pursuits actually protect you against dementia.

Researchers found no link between middle-aged folks taking part in leisure activities and their risk of dementia over the next two decades, according to findings published online Oct. 28 in the journal Neurology.

However, they did discover that some people later diagnosed with dementia will stop participating in leisure activities years before they are diagnosed.

“We found a link between low level of activity in late life and dementia risk, but that this is probably due to people giving up activities as they are beginning to develop dementia,” said lead researcher Andrew Sommerlad, a principal research fellow in psychology at University College London. “Dementia appeared to be the cause, rather than consequence, of low levels of leisure activities.”

These results appear to run counter to the “use it or lose it” theory of brain health, in which numerous prior studies have linked continued engagement in social activities, mental stimulation and physical exercise to a lower risk of dementia.

“Previous studies have tended to look at leisure activities in late life and find an association, but because dementia develops slowly over many years, these studies may not be able to identify the true nature of the relationship,” he said.

Sommerlad said that other factors more directly related to physical health might wind up being more important to protecting the aging brain.

“We do not question the wider benefits of taking part in leisure activities, for promoting enjoyment, quality of life, and general physical and mental health, but other measures have better evidence specifically for dementia prevention,” Sommerlad said. “These are treating health problems like diabetes and hypertension, reducing smoking and alcohol intake, physical activity, treating hearing problems, and having social contact with others.”

For the new study, Sommerlad and his colleagues analyzed data gathered as part of a long-term health study of London-based civil servants that began in 1985.

The researchers looked at data from 8,280 people (average age 56) whose health was tracked for an average of 18 years. Their participation in leisure activities was assessed at the study’s start, five years later and again 10 years later.

Leisure activities included reading, listening to music, using a home computer for fun, taking evening classes, participating in clubs, attending live events or movies, gardening, and playing card or board games. Do-it-yourself home improvements, artistic endeavors, religious activities, going down to the pub, and visiting friends and relatives were also examined.

The researchers found no relationship between a person’s participation in more leisure activities at the start of the study and their dementia risk nearly 20 years later.

They only found a relationship when leisure activities in late life were assessed.

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Living in Noisy Neighborhoods May Raise Your Dementia Risk

Long-term exposure to noise may be linked to an increased risk for Alzheimer’s disease and other forms of dementia.

Researchers did periodic interviews with 5,227 people 65 and older participating in a study on aging. They assessed them with standard tests of orientation, memory and language, and tracked average daytime noise levels in their neighborhoods for the five years preceding the cognitive assessments. About 11 percent had Alzheimer’s disease, and 30 percent had mild cognitive impairment, which often progresses to full-blown dementia.

Residential noise levels varied widely, from 51 to 78 decibels, or from the level of a relatively quiet suburban neighborhood to that of an urban setting near a busy highway. The study is in Alzheimer’s & Dementia.

After controlling for education, race, smoking, alcohol consumption, neighborhood air pollution levels and other factors, they found that each 10 decibel increase in community noise level was associated with a 36 percent higher likelihood of mild cognitive impairment, and a 29 percent increased risk for Alzheimer’s disease. The associations were strongest in poorer neighborhoods, which also had higher noise levels.

The reasons for the connection are unknown, but the lead author, Jennifer Weuve, an associate professor of epidemiology at Boston University, suggested that excessive noise can cause sleep deprivation, hearing loss, increased heart rate, constriction of the blood vessels and elevated blood pressure, all of which are associated with an increased risk for dementia.

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Novel Dementia Risk Charts Underline the Role of Lifestyle

Ten-year dementia risk charts that combine cardiovascular and genetic risk factors have been developed by Danish researchers and graphically underline the impact of modifiable lifestyle factors, even in the face of increased genetic risk.

The research was presented at the European Atherosclerosis Society (EAS) 2020 Virtual Congress, held online this year due to the COVID-19 pandemic, and simultaneously published October 7 in the European Heart Journal.

Ida Juul Rasmussen, MD, PhD, Department of Clinical Biochemistry, Copenhagen University Hospital Rigshospitalet, combined data from more than 60,000 patients — more than 2000 with dementia — with a median follow-up of 10 years.

By combining genetic risk factors with gender and age, as well as lifestyle factors — such as diabetes, smoking, and educational level — they were able to develop a series of risk charts similar to those for cardiovascular risk from the Framingham study.

This showed that a women at least 80 years of age with the highest genetic risk factors who had diabetes, smoked, and had a low educational level would have a 66% risk for dementia over 10 years; this would drop to 45% if she did not smoke or have diabetes and had a higher educational level.

With this pattern repeated across age groups and in both men and women, Rasmussen said that “the overall message from this study is that a healthy cardiovascular risk lifestyle attenuates genetic susceptibility for dementia.”

She added that “by combining genetic risk factors and modifiable risk factors, we are indeed able to identify the individuals at the highest risk of a future dementia disease that would benefit the most” from an intensive lifestyle intervention.

Ralph L. Sacco, MD, professor and chair of neurology and executive director at the Evelyn F. McKnight Brain Institute, Leonard Miller School of Medicine, University of Miami, told theheart.org | Medscape Cardiology that an “important message” of the study is that lifestyle factors still have an appreciable impact on the risk for dementia, even in those at high genetic risk.

“I think the novelty here is the combination of cardiovascular lifestyle factors and the genetics,” Sacco said.

“In the past, there are numerous scores that have been developed on the lifestyle side, some developed on the genetic side, but this group combined both, and I think that makes it an important and well-done comprehensive risk model.”

However, Sacco noted that there were some limitations to the study, saying that the way in which some of the risk factors were defined “is pretty, I would say, crude,” citing, for example, the threshold for hypertension of 140/90 mm Hg blood pressure or medications, or 4 hours a week for high physical activity.

He also believes that the concept of the tables may not fit with the way in which, “nowadays, everybody works with an app and a portable device,” allowing them to enter continuous measures rather than rely on “categorical definitions.”

Sacco added that the very idea of using risk stratification to assign individuals to lifestyle interventions to lower

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