Maintaining a healthy weight can be challenging, particularly during midlife when our metabolisms begin to slow and we need to consume fewer calories or be more active to achieve a healthy weight. While keeping the pounds off can be difficult and frustrating, it’s important we find ways to prioritize healthy living to reduce the risk of developing serious health conditions.

Many people know that carrying excess weight may increase the risk of diabetes, heart disease, and cancer, but many aren’t aware that it may also increase the risk of developing Alzheimer’s disease and other causes of dementia. 

In this article, we will discuss the well-established connection between midlife obesity and Alzheimer’s disease risk, how obesity can impact brain structure and function, and how healthy living may reduce Alzheimer’s and dementia risk.

Midlife Obesity and Alzheimer’s Disease Risk

Excess weight can take a toll on all parts of our bodies—including our brains. Decades of research have shown that obesity may increase the risk of future Alzheimer’s and dementia development. 

Previously, physical inactivity was considered the top modifiable risk factor for Alzheimer’s and related dementias in the United States. However, this has changed in the past decade. In a recent cross-sectional study of data from 378,615 respondents, midlife obesity was identified as the top modifiable risk factor for Alzheimer’s and other dementias in the United States, overtaking physical inactivity. This finding is supported by many other studies. For example, a large longitudinal study found that people with a BMI greater than 30 kg/m² and those with a high sagittal abdominal diameter had a 3.6-fold increased risk of dementia.

So, why is this? Researchers have proposed several mechanisms linking midlife obesity and Alzheimer’s disease. A 2020 imaging study of 17,721 adults found that greater body mass index (BMI) was associated with decreased blood flow in virtually all brain regions, including those influenced by Alzheimer’s disease pathology (e.g., the hippocampus). Others have linked obesity and Alzheimer’s disease through their shared neurodegenerative pathways (e.g., oxidative stress, mitochondrial dysfunction, and inflammation).

Additionally, emerging research suggests that obesity may exacerbate the effects of Alzheimer’s disease. A recent multimodal imaging study found that obesity may contribute to neural tissue vulnerability in both cognitively healthy individuals as well as those with Mild Cognitive Impairment. Their results suggest that maintaining a healthy weight in people living with mild Alzheimer’s disease may help preserve brain structure.

How Obesity Impacts Brain Structure and Function

Throughout the aging process, we all experience minor changes to brain structure and, consequently, brain function. The volume of the brain and/or its weight decreases with age at a rate of approximately 5% per decade after the age of 40. A minor decline in memory function and other cognitive functions—such as complex attention, executive function, and cognitive processing speed—is common during the aging process.

A growing body of research suggests that obesity may accelerate these structural and functional brain changes. In a study of 1,352 participants without dementia, researchers found that midlife vascular risk factors—including obesity, hypertension, and smoking—were associated with an increased progression of vascular brain injury, global and hippocampal atrophy, and a decline in executive function a decade later. Midlife obesity in particular was associated with an increased risk of being in the top quartile of change in executive function and an increasing hip-to-waist ratio was associated with a decline in total brain volume.

Combating Obesity Through Healthy Living

When it comes to obesity, there are several factors at play—some of which we can control and some we cannot. Factors, such as biological and developmental factors (e.g., genetics and developmental conditions) and medical conditions (e.g., hypothyroidism or Cushing’s syndrome) are not modifiable. However, there is still a lot we are in control of—and small changes can make a big difference. 

Modifiable factors that can contribute to weight gain and obesity include: 

• Diet and nutrition 
• Physical activity
• Sleep quantity and quality

One of the easiest ways to get started with healthy living is to start small. Instead of fried chicken, choose grilled chicken. Substitute regular sodas for sugar-free sodas. Choose multigrain or whole wheat pasta instead of white pasta. Get your salad dressing on the side and only use part of it. Opt for the stairs instead of the elevator. Get up and walk for five minutes after every hour of sitting. Go to bed 15 minutes earlier each day until you reach your sleep goal. You don’t have to go on a drastic diet and crazy exercise program to make meaningful changes—start small and create attainable goals.

While there is a connection between obesity and Alzheimer’s disease risk, it doesn’t mean people experiencing weight problems will go on to develop Alzheimer’s, nor does it mean there’s nothing you can do to reduce your risk and take charge of your brain health. 

According to the Michael J. Fox Foundation, approximately 10-20% of people with Parkinson’s disease experience symptoms before age 50. This is known as early- or young-onset Parkinson’s disease. There are distinct genetic and clinical differences between young-onset and idiopathic (late-onset) Parkinson’s disease. It’s important for healthcare providers to be aware of and understand these differences, as this will help reduce the number of misdiagnosed or undiagnosed cases of young-onset Parkinson’s disease.

In this article, we will provide an overview of young-onset Parkinson’s disease, highlight the key differences between young-onset and idiopathic Parkinson’s, and discuss the importance of receiving an early, accurate young-onset Parkinson’s disease diagnosis.

Young-Onset Parkinson’s Disease: Symptoms, Diagnosis, and Treatment

People living with young-onset Parkinson’s disease experience similar symptoms as those living with idiopathic Parkinson’s disease. This includes motor-related symptoms, such as:

• Resting tremor: A tremor, or slight shaking, in the hand, arms, legs, jaw, or face while at rest is a common symptom of Parkinson’s disease. In young-onset Parkinson’s disease, tremors may appear slightly different and faster than those seen in idiopathic Parkinson’s disease.
• Bradykinesia (slowed movement): As the disease progresses, movement can become slow. This can include a reduction in automatic movements (such as swinging the arms when walking or blinking), a general slowness in physical actions, or a mask-like facial expression (decreased expression on the face).
• Rigidity: Stiffness or rigidity in the muscles of the limbs and trunk is common in both young-onset and idiopathic Parkinson’s disease.
• Changes in posture, balance, or gait: Changes in posture, balance and coordination, and gait are common and can cause difficulty walking. When walking, steps can become small, the person’s feet may drag, or they may walk with a shuffle. 

People living with young-onset Parkinson’s disease may also experience non-motor-related symptoms, such as:

• Changes in cognitive function: Changes in cognitive functions, such as memory and thinking, can occur in Parkinson’s disease. However, in people living with young-onset Parkinson’s disease, cognitive function is often preserved for a longer period of time.
• Anxiety and depression: Mood disturbances, such as depression and anxiety, are common in Parkinson’s disease, particularly in the early stages.
• Loss of automatic functions: Parkinson’s disease can affect automatic/involuntary functions performed by the body which may cause constipation, urination problems, excessive sweating, low blood pressure, and sexual problems.
• Sleeping troubles: Sleeping issues are common in Parkinson’s disease and other neurodegenerative diseases and often occur early in the disease course. People may have difficulty falling asleep or staying asleep, thrash around while sleeping, experience daytime sleepiness, or have very vivid dreams.

Like idiopathic Parkinson’s disease, young-onset Parkinson’s is diagnosed “clinically”, meaning diagnosis is dependent on medical history, answers to certain questions, physical examination, and the presence of specific physical symptoms. Because Parkinson’s disease is less common in young adults, the path to diagnosis is often lengthy. Treatment of young-onset Parkison’s disease is similar to that of idiopathic Parkinson’s disease.

Key Differences Between Young-Onset and Idiopathic Parkinson’s Disease

Experts currently believe that young-onset Parkinson’s disease manifests itself differently than idiopathic Parkinson’s disease. Young-onset Parkinson’s disease is associated with different symptom characteristics and different rates of disease progression. Additionally, the development of young-onset Parkinson’s disease is believed to be more likely to be related to genetics compared to idiopathic Parkinson’s disease. Certain genetic mutations, such as in the SNCA, PRKN, PARK7, and PINK1 genes, have been linked to an increased risk of young-onset Parkinson’s disease.

The symptoms and rate of disease progression are often different in young-onset Parkinson’s disease. In general, the disease continuum for young-onset Parkison’s disease spans a longer period of time. People living with young-onset Parkinson’s disease usually remain cognitively and functionally intact for a longer period of time. Additionally, they may experience more side effects from dopaminergic, or dopamine-producing, medications, such as more frequent dyskinesias (involuntary movements).

The Importance of an Early and Accurate Diagnosis

In people living with young-onset Parkinson’s disease, the onset of symptoms typically occurs between 21 and 40 years of age—yet only 2% of people diagnosed with Parkinson’s disease are diagnosed before age 40. Misdiagnosis, or lack of diagnosis, of young-onset Parkinson’s disease is common. Because young-onset Parkinson’s disease manifests itself differently and may require slightly different treatment and management approaches, receiving an early and accurate diagnosis of young-onset Parkinson’s is essential for receiving precise, personalized treatment and care. Additionally, younger individuals with Parkinson’s disease are often better candidates for certain surgical and medical interventions.

Parkinson’s disease, while a chronic condition, can be well managed—but this is often dependent on receiving an early and accurate diagnosis. This is particularly important for people living with young-onset Parkinson’s disease, as, at this stage in their life, they may be raising children, working on advancing their careers, or even starting a new chapter of their lives. 

More than 55 million people worldwide are living with Alzheimer’s disease or other dementias. This number is expected to nearly triple to more than 152 million by 2050. Currently, there is no cure for Alzheimer’s disease or other causes of dementia, however, researchers, scientists, and pharmaceutical companies around the globe are making great strides toward a future without Alzheimer’s disease. 

Fundamental to this goal is the ability to raise awareness, as this will promote early intervention, reduce dementia incidence, accelerate scientific progress and drug development, and erode the stigma that persists around Alzheimer’s and dementia.

In this article, we discuss the importance of Alzheimer’s and dementia awareness and the crucial role awareness plays in finding effective disease-modifying treatments.

Alzheimer’s Disease and Dementia

Dementia is an umbrella term used to describe a group of symptoms associated with a decline in memory, thinking, reasoning, or other cognitive functions. There are many causes of dementia, including Alzheimer’s disease, vascular dementia, Lewy body dementia, Parkinson’s disease, and Huntington’s disease. Alzheimer’s disease is the leading cause of dementia, accounting for approximately 60-80% of all dementia cases.

Alzheimer’s is a degenerative neurological disease characterized by a gradual decline in neurocognitive function, meaning there is a decline in both cognitive and functional aspects of brain function (how you think and how you move). Many people living with Alzheimer’s disease also experience behavioral and psychological symptoms. 

Memory loss is often one of the first symptoms reported by people living with Alzheimer’s disease and their loved ones. The primary underlying cause of memory loss, confusion, and forgetfulness in those living with Alzheimer’s disease is the progressive damage that accompanies the disease. This progressive damage is thought to be largely due to Alzheimer’s pathology—namely beta-amyloid plaques and neurofibrillary tangles. 

Awareness Matters: The Importance of Alzheimer’s and Dementia Awareness

There is often a lack of awareness and understanding of Alzheimer’s disease and dementia which can contribute to stigmatization and create harmful barriers to diagnosis, treatment, and care. Raising Alzheimer’s and dementia awareness will bring widespread knowledge about factors that contribute to Alzheimer’s and dementia development, symptoms to watch for, and dementia prevention strategies. With this knowledge comes a breadth of benefits for patients and their loved ones, healthcare providers, and healthcare systems alike.

1) Awareness Promotes Early Intervention by Eroding the Stigma

Like many other diseases and disorders, early intervention and early treatment of Alzheimer’s disease and other causes of dementia is believed to offer the best chance of therapeutic success and produce better health outcomes. This is particularly important with the recent approval of Aducanumab (ADUHELM™) for mild cognitive impairment (MCI) or mild Alzheimer’s disease. Early detection is essential to receiving earlier access to treatments as well as gaining access to treatments, like Aducanumab, that are only approved for the early stages of Alzheimer’s disease.

Lack of knowledge of the symptoms of Alzheimer’s and dementia is a significant barrier to early intervention. When many people think of dementia, they think of memory loss—but Alzheimer’s and other causes of dementia can cause a breadth of cognitive, functional, behavioral, and psychological symptoms that many people aren’t aware of. There are also many other possible causes of memory loss that people should be aware of, like a head injury; certain thyroid, liver, and kidney disorders; and vitamin deficiencies. Bringing awareness to symptoms of Alzheimer’s disease and dementia can help enable timely medical intervention.

The stigma and misconceptions surrounding Alzheimer’s and dementia can prevent people who may be experiencing symptoms of dementia from:

• Receiving an early diagnosis (or any diagnosis at all)
• Seeking medical care when symptoms are present
• Taking advantage of the benefits of available treatments 
• Participating in clinical trials
• Creating a support system

Alzheimer’s and dementia awareness erodes the stigma and associated misconceptions and encourages those experiencing symptoms to seek medical treatment. 

2) Awareness Around Risk Factors for Dementia Can Lower the Incidence of Dementia at Scale

Dementia is not an inevitable part of aging. While Alzheimer’s and dementia are not considered preventable, there are many steps people can take to reduce their risk of developing dementia later in life. While some factors involved in dementia development, such as genetics and age, can’t be changed, many risk factors for dementia are modifiable. 

We now know there are 12 potentially modifiable risk factors for dementia. These include:

• Less education
• Hearing loss
• Traumatic brain injury
• Hypertension (high blood pressure)
• Alcohol consumption (>21 units/week)
• Obesity
• Smoking
• Depression
• Social isolation
• Physical inactivity
• Air pollution
• Diabetes

There is so much we can do to promote brain health and reduce the risk of developing dementia. By raising awareness around these risk factors and educating the public on how to promote healthy cognitive aging, we can reduce the incidence of dementia at scale. This not only benefits the health of the general public but also reduces the rising global economic burden of dementia.

3) Awareness Accelerates Scientific Progress and Drug Development

One of the biggest barriers to accelerating scientific progress and getting effective drugs to market is getting enough people to participate in research studies and clinical trials. The average patient dropout rate across all clinical trials is 30%, with 85% of all clinical trials failing to retain an adequate number of subjects to successfully complete a study. 

Research studies and clinical trials are not just seeking people living with Alzheimer’s or other dementias for these studies and trials—they are also seeking healthy adults without dementia. Traditionally, clinical trials are designed around the locations of research centers to recruit subjects from the local population. However, the digital healthcare transformation, along with the COVID-19 pandemic, has catalyzed the implementation of decentralized clinical trials. This not only makes it easier for people to participate in clinical trials by breaking down geological barriers but also provides improved data diversity—a crucial element of many Alzheimer’s disease clinical trials.

Increasing awareness around the need for more subjects and around the benefits of participating in clinical trials can break down these barriers and, in turn, accelerate scientific progress and drug development.

Alzheimer’s disease, the most common cause of dementia, is a degenerative neurological disease characterized by a gradual decline in neurocognitive function. Alzheimer’s disease affects more than memory—throughout the disease, people living with Alzheimer’s typically experience a range of cognitive, functional, behavioral, and psychological symptoms.

As the disease progresses and these symptoms worsen, it is common for complications to arise. Learning about common Alzheimer’s disease complications can help healthcare providers and caregivers proactively identify complications and provide personalized care and treatment to meet patients’ changing needs.

Common Alzheimer’s Disease Complications

In addition to failing memory, there are a host of issues that could result because of Alzheimer’s. Common complications of the disease include:

• Behavioral and psychological changes 
• Flu, pneumonia, and other infections
• Sleep problems
• Falls and injury
• Bladder and bowel issues
• Malnutrition and dehydration
• Dental problems

Behavioral and Psychological Changes

Personality and behavioral changes are common in people living with Alzheimer’s disease. Common changes include:

• Aggression, anger, and agitation
• Anxiety and depression
• Apathy
• Paranoia and fear
• Delusional thinking
• Wandering
• Loss of interest in previously enjoyed activities
• Social withdrawal
• Lack of initiative
• Inability to make decisions 
• Insensitivity to others

Flu, Pneumonia, and Other Infections

Infection is a common Alzheimer’s disease complication. In the later stages of Alzheimer’s disease, patients are more vulnerable to infections, especially pneumonia. This is believed to be due to the altered immune response associated with Alzheimer’s. Additionally, many patients are unable to move around due to impaired function and, consequently, unable to perform Activities of Daily Living (ADLs) without around-the-clock caregiver assistance. This can lead to poor oral and personal hygiene, scrapes or cuts that don’t get cleaned, and aspiration of food or beverages which can all lead to infection. 

While Alzheimer’s affects everyone differently, many patients are unable or not always able to communicate their feelings and needs in the late stages, making it difficult for them to communicate if they’re feeling ill or are in pain.

Sleep Problems and Sundowning

Sleep problems are common in people living with Alzheimer’s disease, and it’s often one of the earliest reported symptoms. They may experience difficulty falling asleep, difficulty staying asleep, changes in their sleep-wake patterns, or daytime drowsiness. In the late afternoon, they may experience changes in behavior and mood—such as confusion, agitation, anxiety, irritability, and disorientation—as the sun begins to set. This is known as sundowning.

Falls and Injury

Individuals with Alzheimer’s disease and other causes of dementia are at a significantly higher risk of falling and injuring themselves. Falls affect between 60% to 80% of individuals with cognitive impairment. Individuals with dementia are up to three times more likely to sustain a hip fracture compared to cognitively intact older adults.

Alzheimer’s disease, particularly in the later stages, can affect function in addition to cognition. While functional impairments contribute to falls, several aspects of cognition can contribute significantly to increased fall risk. Even if an Alzheimer’s disease patient has minimal to zero balance impairment, they may still be at risk of falls due to cognitive changes. Cognitive functions, such as executive function, play a critical role in the regulation of gait and, consequently, cognitive impairment can lead to falls. Additionally, behavioral changes, such as wandering, pacing, agitation, and restlessness, can lead to falls.

Bladder and Bowel Issues

As Alzheimer’s disease progresses and functional impairments become more severe, many patients experience incontinence of the bladder and bowels. This can be due to several different causes. People living with Alzheimer’s disease may not recognize the need to use the restroom, they may forget where the bathroom is, or be experiencing incontinence as a side effect from medications (e.g., sleeping medications and anxiolytic drugs). Comorbidities can also contribute to bladder and bowel issues. Diabetes, for example, can cause nerve damage in the urinary tract which can lead to bladder problems. Other comorbidities that may cause incontinence include stroke and muscular disorders, such as Parkinson’s disease.

Malnutrition and Dehydration

In the middle and late stages of Alzheimer’s disease, it can be challenging to ensure patients get consistent, nutritious meals. They may be overwhelmed by food choices or forget to eat, as they think they have already eaten. Additionally, as Alzheimer’s disease progresses, many patients experience dysphagia, or swallowing difficulties, which can contribute to difficulty staying hydrated and getting enough nutrients. An estimated 45% of dementia patients in long-term care facilities have some degree of swallowing difficulty. 

Dental Problems

Dental problems are a common Alzheimer’s disease complication. Patients may forget the importance of dental hygiene, they may forget to brush their teeth, they may not remember the proper sequencing for brushing their teeth, or they may be resistant to assistance from caregivers. This can ultimately lead to tooth decay, gum disease, and other dental problems. Additionally, poor oral hygiene is known to increase the risk of aspiration pneumonia.

With age often comes new health challenges. During our lifetimes, many of us will experience visual impairment. An estimated 20% of adults aged 85 years and older in the US are blind or have visual acuity impairment. Recently, research has uncovered a relationship between vision and dementia.

There are two aspects linking vision and dementia:

1. Visual impairment may be a modifiable risk factor for dementia.
2. Individuals with dementia often experience changes in visual perception.

In this article, we will take a look at these two aspects and discuss important implications of this connection.

Visual Impairment: A Potential Risk Factor for Dementia

Recent research has shed light on the role of sensory impairment in Alzheimer’s and dementia risk. While the link between hearing loss and dementia risk is well-established, with hearing loss accounting for 8% of global dementia cases, the link between vision loss and dementia risk is just beginning to be established. Research is still limited in this space, however, early research indicates a similar connection exists between vision status and dementia risk.

A 2018 longitudinal study found that participants who rated their vision as moderate were two times as likely as those with normal vision to have dementia, and those who rated their vision as poor were four times as likely.

A 2022 systematic review and meta-analysis of the association between visual impairment and cognitive outcomes included 16 studies totaling 76,373 participants. They found that visual impairment was associated with an increased risk of dementia and cognitive decline, as evident in cross-sectional and longitudinal studies. This raises the question of whether or not treatment of visual impairment, such as wearing glasses and removing cataracts, could reduce the risk of cognitive impairment and dementia.

A 2021 study assessed the association between cataract extraction and the development of dementia. The study assessed 3,038 adults aged 65 years or older with cataracts enrolled in the Adult Changes in Thought study. Even after adjusting for additional influential variables, such as years of education, race, smoking history, sex, and age at cataract diagnosis, the study found that individuals who underwent cataract removal surgery had nearly a 30% lower risk of developing dementia compared to those without the surgery. 

In short, visual impairment is considered a modifiable risk factor for dementia, but it’s unclear why. Some experts hypothesize visual impairment may contribute to social isolation, reduced physical activity, and depletion of cognitive reserve, ultimately increasing dementia risk. Further research is needed to determine whether screening and treatment for vision loss may slow cognitive decline.

Vision and Dementia: Changes in Visual Perception

Dementia is known to cause a breadth of changes in the brain and, consequently, neurocognitive changes in a range of domains. Among commonly impacted neurocognitive domains is visual perception—our ability to visualize and interpret our surroundings.

Different causes of dementia can damage the visual-perceptual system in diverse ways depending on how the disease alters the structure of the brain. Common changes in visual perception may include:

• Diminished ability to detect movement
• Reduced peripheral vision range
• Decreased sensitivity to variations in the contrast between objects and background
• Reduced ability to see between colors
• Issues directing or shifting gaze
• Decreased sensitivity to depth perception 
• Difficulty recognizing objects and faces

Along with other cognitive changes, these changes can contribute significantly to behavioral and psychological symptoms of dementia (BPSD) and increase the risk of falls and serious injury. Issues with visual perception can affect patients’ abilities to carry out Activities of Daily Living (ADLs). For example, someone living with dementia who has difficulty distinguishing between colors may pick out mismatched clothing or not notice white rice on a white dinner plate. Someone who is experiencing reduced peripheral vision range may bump into furniture while walking through a hallway. 

The Connection Between Vision and Dementia: Implications

As a whole, this emerging body of research has important implications. First and foremost, preventive steps should be taken to prevent visual impairment, as this may reduce the risk of developing dementia later in life. Additionally, individuals with non-treatable visual impairment may benefit from more frequent neurocognitive testing to detect changes as early as possible.

Nearly 80% of visual impairment and 25% of blindness in the US are considered preventable or treatable with prescription glasses and surgical cataract treatment—both of which have a high cost- and clinical-effectiveness. This highlights the importance of receiving treatment for visual impairment.

While changes in visual perception in those living with dementia is not a new finding, it does highlight the importance of routine neurocognitive assessments in senior living facilities. Because visual perception can increase fall risk and impact patients’ abilities to complete ADLs, routine testing can provide valuable insights to caregivers, allowing them to adapt care plans to patients’ changing care needs.

As we age, many of us notice small changes in our cognitive abilities. Maybe you take longer to remember an old friend’s name or maybe you forget to pay a bill every once in a while. Throughout the aging process, your brain experiences minor structural changes, and consequently, you experience minor cognitive changes. But when are these changes a sign of cognitive decline?

Learning about the common signs of cognitive decline, the importance of routine cognitive testing, and how to measure cognitive changes can help you bring awareness to your brain health.

What Is Cognitive Decline?

Cognitive decline can range from Mild Cognitive Impairment (MCI) to dementia. Both are broad terms that indicate a decline in cognitive function greater than normal age-related decline. 

MCI is currently thought of as the stage between expected age-related cognitive decline and dementia. Individuals with MCI experience cognitive changes that are significant enough to be noticed by family and friends, but not significant enough to affect everyday function. MCI can be due to a variety of conditions, including neurological diseases such as Alzheimer’s disease and Parkinson’s disease and other conditions such as depression, thyroid problems, liver or kidney problems, and sleep disorders, among others. It’s important to note that having MCI does not necessarily mean you will go on to develop dementia. According to the Alzheimer’s Association, an estimated 10-15% of people living with MCI develop dementia each year. 

Dementia is an umbrella term used to describe a group of symptoms associated with a decline in memory, thinking, reasoning, or other cognitive abilities. These symptoms may include a decline in memory, changes in thinking or problem-solving abilities, poor reasoning and judgment skills, changes in language and communication abilities, and changes in personality and behavior.

There are several causes of dementia, including the following:

• Alzheimer’s disease
• Lewy Body dementia
• Vascular dementia
• Frontotemporal dementia
• Mixed dementia
• Huntington’s disease
• Parkinson’s disease dementia
• Creutzfeldt-Jakob disease
• Posterior cortical atrophy

Many neurodegenerative diseases can be thought of as a continuum with distinct clinical phases. Within these continuums, MCI is often an early stage. For example, MCI due to Alzheimer’s disease is stage two of five in the Alzheimer’s disease continuum.

Signs of Cognitive Decline

As we mentioned above, there are many potential causes of cognitive decline. As a result, symptoms can vary depending on the cause and severity of cognitive decline. There are, however, signs of cognitive decline that may indicate you are experiencing a decline in function greater than the expected age-related decline. This may include:

• Repeatedly asking the same questions
• Getting lost in familiar places
• Losing or misplacing things often
• Difficulty understanding time and place
• Forgetting important events, such as social engagements and appointments
• Losing your train of thought or having difficulty coming up with the right word
• Difficulty with decision-making or planning
• Changes in judgment and impulse control
• Struggling to follow a list of instructions (e.g., a recipe or driving directions).
• Changes in mood (e.g., anxiety, depression, apathy, and irritability)

Routine medical check-ups and cognitive testing are key to detecting signs of cognitive decline as early as possible.

The Importance of Early, Routine Cognitive Screening

Approximately 75% of dementia cases go undiagnosed until it is too late. Like many other diseases and disorders, early intervention and early treatment of Alzheimer’s disease and other causes of dementia is believed to offer the best chance of therapeutic success and produce better health outcomes. 

Whether you’re 30 or 70, cognitive testing should be as normal as going to the dentist. It is never too early to prioritize and take charge of your brain health. After all, it is a vital part of overall wellness and plays a key role in our ability to live long, healthy, and full lives.

Measuring Cognitive Decline

To accurately measure cognitive decline, it is necessary to regularly and frequently assess brain function over time. By tracking trends and patterns in assessment scores longitudinally, signs of cognitive decline can be identified.

To do so, your healthcare provider may use cognitive assessment tools such as the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), the Mini-Cog, and the general practitioner assessment of cognition (GPCOG). These assessments typically require you to answer a series of questions and/or complete simple tasks to determine your cognitive abilities in areas such as learning and memory, orientation, attention, and visuospatial abilities. Assessments utilize scoring systems to quantify your cognitive function.

Unfortunately, these assessments don’t come without limitations. Most of these traditional assessments only assess a small subset of neurocognitive (cognitive and functional) domains. Because such assessments are not designed to analyze how we function in real-world settings, they often produce noisy, highly variable results that lack the specificity to detect small changes in cognition over time.

As we age, it’s common to worry about the possibility of developing dementia. While aging is the greatest risk factor for dementia, it’s much more complicated than that—there are many causes of dementia and many risk factors associated with its development.

Around the globe, researchers have banded together to identify risk factors and explore methods to prevent dementia. While there is currently no definitive way to prevent dementia, there is strong evidence to suggest several aspects of healthy living may reduce your risk of developing dementia.

Potential Ways To Prevent Dementia

According to the 2020 Lancet Commission on dementia prevention, intervention, and care, three new potentially modifiable risk factors have been identified: excessive alcohol consumption, air pollution, and traumatic brain injury. With this, there are now 12 potentially modifiable risk factors for dementia. Their life-course model of dementia prevention includes one early life risk factor, five midlife risk factors, and six later life risk factors. Together, these risk factors are believed to account for approximately 40% of worldwide dementia cases. In other words, modifying these 12 risk factors may prevent or delay up to 40% of dementia cases.

Early life risk factors are believed to impact cognitive reserve, the brain’s ability to make thicker connections between brain areas and cope with, or moderate, the clinical consequences of a disease. Midlife and later life risk factors are believed to play a role in age-related cognitive decline and may trigger neuropathological changes in the brain.

Taking steps throughout all stages of life to modify risk factors and protect brain health may help prevent dementia.

Potential Risk Factors for Dementia During Early Life

During early life (younger than 45 years), education is the primary factor that is believed to contribute to dementia risk. You can think about education as the foundation for cognitive reserve to be built upon. Higher educational attainment may increase cognitive reserve while lower educational attainment may decrease cognitive reserve. Accordingly, higher educational attainment is associated with a lower risk of dementia while lower educational attainment is associated with a higher risk of dementia. 

Modifying this risk factor by increasing educational attainment at a global scale could prevent or delay 7% of dementia cases.

Potential Risk Factors for Dementia During Midlife

During midlife (45-65 years), there are five potentially modifiable risk factors associated with dementia development: hearing loss, traumatic brain injury (TBI), hypertension, excessive alcohol consumption, and obesity.

• Hearing loss: Hearing loss is believed to account for 8% of worldwide dementia cases, making it the largest known potential modifiable risk factor for dementia. Noise-induced hearing loss is a preventable, and in most cases, treatable condition. Studies have also correlated the use of hearing aids in hearing-impaired individuals with reduced dementia risk.

• TBI: Single, severe TBI—where severe TBI is defined as skull fracture, edema, brain injury, or bleeding—has been linked to widespread hyperphosphorylated tau pathology in both human and animal studies. Consequently, TBI has been linked to Alzheimer’s disease, the most common cause of dementia. TBI is believed to account for 3% of global dementia cases. 

TBI is most commonly caused by falls, motor vehicle crashes, and recreational sports. Taking appropriate safety precautions, such as wearing seatbelts and appropriate headgear, can reduce the risk of TBI.

• Hypertension: Accounting for approximately 2% of global dementia cases, midlife hypertension may contribute to dementia risk. Healthy living—such as eating a heart-healthy diet, regularly exercising, limiting alcohol consumption, quitting smoking, and getting enough sleep—can improve the health of the heart and blood vessels and may reduce the risk of hypertension.
• Excessive alcohol consumption: Excessive alcohol consumption, characterized as drinking more than 21 units of alcohol each week, is a newly identified risk factor that is thought to account for 1% of all dementia cases. Addressing mental illness and implementing substance abuse prevention programs may reduce substance misuse and related harms, including elevated dementia risk.
• Obesity: Obesity, defined as having a body mass index (BMI) of 30 or greater, has been associated with late-life dementia and may be responsible for 1% of dementia cases. Elements of healthy living, such as those mentioned above for hypertension prevention, can help prevent and manage obesity.

Potential Risk Factors for Dementia During Later Life

During later life (older than 65 years), there are six potentially modifiable factors that have been linked to dementia: smoking, depression, physical inactivity, air pollution, and diabetes.

• Smoking: Individuals who smoke cigarettes are at a higher risk of developing dementia. Smoking may account for 5% of global dementia cases. Research has also shown that smokers who quit smoking, even later in life, may benefit from reduced dementia risk. Duration and intensity of smoking, as well as time after smoking cessation, are believed to influence risk. 
• Depression: While depression is often an early symptom of dementia, depression during later life is thought to increase dementia risk, accounting for approximately 4% of worldwide dementia cases. Studies have shown that long-term selective serotonin reuptake inhibitor (SSRI) treatment of depression is associated with delayed progression from mild cognitive impairment (MCI) to clinically diagnosed Alzheimer’s disease.
• Social isolation: Novel social interactions are believed to play an important role in strengthening the cognitive reserve during middle and later life. Less social contact may deplete the cognitive reserve, thus increasing dementia risk. Increased social contact may provide a protective effect against dementia and could delay or prevent dementia in 4% of all cases.
• Physical inactivity: Regular physical activity helps maintain a healthy weight and reduces the risk of cardiovascular conditions, including hypertension and hypercholesterolemia. Physical inactivity has been associated with an elevated risk of dementia and may account for 2% of dementia cases.
• Air pollution: Air pollution is a newly identified potentially modifiable risk factor for dementia, accounting for approximately 2% of dementia cases. Research suggests that airborne particulate pollutants may accelerate neurodegenerative processes. Examples of air pollutants that may increase dementia risk include exposure to high nitrogen dioxide concentrations and particulates from traffic exhaust or wood burning.
• Diabetes: Diabetes is believed to contribute to 1% of dementia cases. Reducing the prevalence of obesity and other conditions associated with diabetes through healthy living can reduce diabetes prevalence and contribute to reduced dementia prevalence. Some studies have shown that long-term glycemic control in those living with diabetes may reduce dementia risk, however, evidence is still limited.

While these risk factors provide compelling evidence that there may be ways to prevent dementia or at least delay its onset, there is a second part of this equation that should be addressed.

Routine testing of cognitive function for all adults—especially those at higher risk of developing dementia—is essential for the early detection of Alzheimer’s and other causes of dementia. This is particularly true as we see promising new treatments and therapies emerge in the drug development pipeline.

Whether you are a caregiver or a family member of someone living with dementia, you may notice changes in their behavior as you enter the late afternoon or early evening. Sundowning—also known as ‘sundown syndrome’ or ‘late-day confusion’—is a common manifestation among people living with dementia. 

Late afternoon and early evening can be a challenging time of day for dementia patients as well as their caregivers and loved ones. Fortunately, there are a number of strategies that may help to prevent and manage sundowning in dementia patients.

In this article, we will discuss potential causes of sundowning in dementia patients and tips for coping with and managing sundowning.

Potential Causes of Sundowning in Dementia Patients

Sundowning refers to the emergence or increment of neuropsychiatric symptoms, such as confusion, agitation, anxiety, irritability, and disorientation, occurring in the late afternoon and early evening. Based on data available from the Alzheimer’s Association, researchers believe approximately 20% of patients diagnosed with Alzheimer’s disease experience sundown syndrome. This clinical phenomenon has also been reported in other causes of dementia, including vascular dementia, frontotemporal dementia, and Lewy body dementia.

Although the underlying cause of sundowning in dementia patients is not yet fully understood, researchers believe sundowning may be related to impaired circadian rhythm, environmental and social factors, and impaired cognition. 

More specifically, potential factors that may contribute to sundowning in dementia patients include:

• Mental and physical fatigue due to a confusing or unfamiliar environment
• Disturbance of the patient’s ‘biological clock’ (circadian rhythm)
• Fluctuations in hormone levels throughout the day
• Mood disorders (e.g., anxiety and depression)
• Disorientation 
• Reduced sleep quantity or quality
• Low lighting and shadows
• Nonverbal behaviors of others

Sundowning can be aggravated by feelings of hunger, thirst, fatigue, pain, and boredom. Other factors, such as side effects from medications or changes in daily routine, can also contribute to the phenomenon.

Tips for Coping With Sundowning in Dementia Patients

In the early afternoon and early evening be cognizant of the patient’s behavior. Watching for signs, such as pacing, wandering, shadowing (closely following you wherever you go), crying, and other confusion- or anxiety-related behaviors.

To help patients cope with and manage late-day confusion, be sure to take the time to listen to their frustrations and concerns. Always be patient, bring a comforting presence, and try to understand the potential causes of their behaviors. Offer reassurance that they are safe and everything is alright. Take notes on the timing of sundowning and activities that occur beforehand to help identify potential triggers.

You may also consider:

• Reducing noise and activity in the room to reduce stress
• Distracting the patient with a favorite activity, image, object, or snack
• Playing soothing music, reading a book, playing a card game, doing a puzzle, or going for a walk
• Closing the blinds or curtains and turning on the lights prior to sundown

In addition, keep in mind that it is not always sundowning—similar behaviors can result from other feelings or needs such as needing to use the bathroom, being hungry or thirsty, or being in pain. 

Tips To Prevent Sundowning in Dementia Patients

While these behavioral changes are not always preventable, there are steps you can take that may help prevent sundowning and manage sleep issues associated with dementia. You may consider:

• Providing a predictable, stable routine for bedtime, waking, activities, and meals
• Limiting daytime napping or decreasing daytime napping duration
• Ensuring sufficient physical activity during the day
• Including time outside in the sunlight during the day (or by a window with sunlight)
• Encourage good sleep hygiene 
• Avoiding or limiting sugar, caffeine, alcohol, and nicotine intake to the morning hours
• Providing a larger lunchtime meal and smaller/lighter evening meal
• Keeping the living space or patient’s room well-lit during the evening hours
• Engaging the patient in soothing activities around the time sundowning symptoms typically arise
• Reducing stimulation in the evening hours
• Scheduling any appointments or outings in the morning or early afternoon hours

Caregivers and family members may also consider talking to the patient’s healthcare team about other solutions or other potential causes of sundowning-like behaviors, particularly if non-drug approaches are unsuccessful.

Alzheimer’s disease is a complex and debilitating condition that, until recently, had no FDA-approved treatments that go beyond symptom management to slow or halt its progression. Eisai’s lecanemab (Leqembi) is the second FDA-approved treatment for Alzheimer’s disease to enter the market since 2003, sparking immense hope for neurologists and patients alike in the fight against Alzheimer’s disease.

In addition to the first generation of disease-modifying therapies, there are several drugs, therapies, and lifestyle interventions that can be used to manage the symptoms of Alzheimer’s disease.

In this article, we will walk you through the current approaches for the treatment of Alzheimer’s disease, including:

• Disease-modifying therapies
• Drugs to manage cognitive symptoms
• Drugs to manage behavioral changes
• Adjunct therapies and lifestyle interventions

Disease-Modifying Therapies

Historically, treatment of Alzheimer’s disease was centered around alleviating the symptoms that result from the pathological changes in the brain and, consequently, the loss of neurons in various brain regions. However, a new class of therapies, known as monoclonal antibody therapies, aims to modify the disease course. 

In 2021, Aducanumab received accelerated approval from the FDA for the treatment of Alzheimer’s disease, marking the first FDA-approved drug in the monoclonal antibody therapy class. Lecanemab, the second FDA-approved drug in this class, also addresses the underlying pathology of Alzheimer’s disease by targeting and reducing beta-amyloid plaques early in the initial stages of the disease.

Clinical trial data released on November 29, 2022, demonstrated lecanemab was effective in reducing beta-amyloid plaques and slowing cognitive decline for some patients. On January 6, 2023, lecanemab received accelerated approval from the FDA for Alzheimer’s disease treatment. Compared to aducanumab, lecanemab was found to have a higher safety profile and to bind more strongly to beta-amyloid protofibrils, representing a key milestone in the fight against Alzheimer’s disease.

On April 7, 2022, the Centers for Medicare and Medicaid (CMS) released a national policy coverage for aducanumab as well as any future monoclonal antibodies directed against beta-amyloid approved by the FDA for the treatment of Alzheimer’s disease. Because lecanemab was granted accelerated approval by the FDA, it falls under CMS’s existing national coverage determination. 

Drugs to Manage Cognitive Symptoms

Addressing the cognitive symptoms of Alzheimer’s disease can help preserve a person’s independence and maintain quality of life. There are several FDA-approved prescription drugs that may be used to manage cognitive symptoms in people living with Alzheimer’s disease. 

In the mild to moderate stages of Alzheimer’s disease, cholinesterase inhibitors are commonly prescribed to treat cognitive symptoms, such as issues with memory, language, thinking, and judgment. In the moderate to severe stages of Alzheimer’s disease, glutamate regulators are often prescribed to decrease symptoms and improve cognitive functions such as memory, language, reason, and attention.

Cholinesterase inhibitors work by preventing the breakdown of acetylcholine (a neurotransmitter important for learning and memory). Glutamate regulators work by regulating the activation of glutamate (a neurotransmitter important for synaptic plasticity and survival of neurons) and blocking the toxic effects of excessive glutamate. Cholinesterase inhibitors and glutamate regulators can also be used in combination in some cases (Namzaric^Ⓡ).

Drugs to Manage Behavioral Changes

For many friends, families, and caregivers, behavioral changes can be the most distressing and difficult parts of caring for someone living with Alzheimer’s disease. As the disease progresses and regions of the brain, such as the frontal lobe, become damaged, people living with Alzheimer’s disease often experience non-cognitive symptoms, such as irritability, anxiety, depression, hallucinations, delusions, and disturbed sleep.

Non-drug interventions are often the first line of defense for behavioral changes. However, there are several medications that may be prescribed when appropriate.

Note: Most of the examples above represent “off-label” drug use, which is when an FDA-approved medication is prescribed for a different condition than the one it was originally approved for. For example, while citalopram is FDA-approved specifically to treat depression (not Alzheimer’s), it may be used to manage depression in those living with Alzheimer’s disease.

Treatment of Alzheimer’s Disease: Therapies and Lifestyle Interventions

In addition to medications, treatment of Alzheimer’s disease may involve adjunct therapies, such as those detailed below:

• Cognitive Stimulation Therapy (CST): CST is a short-term, evidence-based intervention program for patients with mild to moderate Alzheimer’s disease (or mild to moderate dementia due to other causes). CST involves a series of themed activities designed to actively stimulate and engage patients socially and mentally. 
• Reminiscence Therapy: Reminiscence therapy integrates the use of the five senses—sight, touch, taste, smell, and sound—to help Alzheimer’s patients recall specific positive memories. The overarching school of thought for this approach lies in the idea that if a patient engages in activities that evoke memories, it may wake up certain neural connections and reactivate dead parts—like jumper cables for the brain.
• Occupational Therapy: Occupational therapy helps Alzheimer’s and dementia patients maintain their quality of life and remain as independent as possible through specific intervention strategies. Types of occupational therapy include health promotion, remediation, maintenance, and modification.

Effective treatment and management of Alzheimer’s disease require a well-rounded approach. Lifestyle interventions often play an essential role in preserving the overall health and well-being of Alzheimer’s patients and can help manage behavioral and psychological symptoms. Lifestyle interventions may include routine exercise, weight management, diet and nutrition, social and mental stimulation, stress reduction, and sleep hygiene.

Monitoring the Effects of Treatment in Alzheimer’s Patients

Regardless of the drugs, therapies, or lifestyle interventions involved in a patient’s treatment and management plan, healthcare providers and caregivers should consider monitoring the neurocognitive effects of treatment. Routine neurocognitive assessments can not only provide insight into how well the treatment plan is working but can also further inform care needs and identify patients who may be at risk of falls to prevent serious injury.

To learn more about how Alzheimer’s disease is treated, listen to this podcast sponsored by Altoida: Treatment for Alzheimer’s Disease (Part 2): Medication and Rehabilitation Therapies.