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Meta-analysis is the statistical procedure for combining data from multiple studies.

Combined work of 24 international experts

One in three cases of dementia could be prevented

It examines the benefits of building a "cognitive reserve", which means strengthening the brain's networks so it can continue to function in later life despite damage.

For short quotes, the standard two-line format works perfectly. You can either stretch the quote across the two lines, or use the first line for the quote and the second line for the speech title or the date.

Low educational level is thought to result in vulnerability to cognitive decline because is results in less cognitive reserve.

Cognitive reserve enables people to maintain function despite brain pathology


Less education is associated with an RR of dementia
of 1·59 (95% CI 1·26–2·01) and the high PAF is because
of the large worldwide estimated prevalence of 40%.
Less time in education, which we defined as no
secondary school education, has the second highest
PAF in our model. Low educational level is thought to
result in vulnerability to cognitive decline because it
results in less cognitive reserve,58 which enables people
to maintain function despite brain pathology.80 We do
not yet know whether education after secondary school
is additionally protective

Mid-life hearing loss

Hearing
Recognition of hearing loss as a risk factor for dementia
is relatively new and has not been included in previous
calculations of PAF, nor has it been a priority in the
management of those at risk of cognitive impairment.
Results of cohort studies65–67,81–88 that have investigated
hearing have usually shown that even mild levels of
hearing loss increase the long-term risk of cognitive
decline and dementia in individuals who are cognitively
intact but hearing impaired at baseline. However,
although there are 11 positive studies, two studies89,90
found no increased risk in adjusted analyses.
The risk of hearing loss for dementia in the metaanalysis
of three studies,65–67 which we did for this
Commission (pooled RR 1·94, 95% CI 1·38–2·73; figure 3),
is not only higher than the risk from other individual risk
factors, but it is also pertinent to many people because it is
highly prevalent, occurring in 32% of individuals aged
older than 55 years.91 Its high RR and prevalence explains
the high PAF. We have used the prevalence of hearing loss
in individuals older than 55 years to calculate PAF because
this age was the youngest mean age in which presence of
hearing loss was shown to increase dementia risk.67
Hearing loss is therefore grouped with the midlife risk
Late life
Hearing loss
Percentage reduction
if this risk is eliminated
Hypertension
Obesity
Early life
Midlife
ApoE ε4
Smoking
Depression
Physical inactivity
Social isolation
Diabetes
8%
9%
5%
5%
4%
3%
2%
1%
2%
1%
7%
Less education
Potentially
non-modifiable
65%
Potentially
modifiable
35%
Figure 4: Life-course model of contribution of modifiable risk factors to dementia
Numbers are rounded to nearest integer. Figure shows potentially modifiable or non-modifiable risk factors.
The Lancet Commissions
2680 www.thelancet.com Vol 390 December 16, 2017
factors, but evidence suggests that it continues to increase
dementia risk in later life.
The mechanism underlying cognitive decline associated
with peripheral hearing loss is not yet clear; nor is it
established whether correction, such as hearing aids,
can prevent or delay the onset of dementia. Older
age and microvascular pathology increase the risk of
both dementia and peripheral hearing loss, and might
therefore confound the association. Hearing loss might
either add to the cognitive load of a vulnerable brain
leading to changes in the brain,92 or lead to social
disengagement or depression93,94 and accelerated atrophy,95
all of which could contribute to accelerated cognitive
decline.96 Although impaired hearing might detrimentally
affect performance on formal cognitive assessments,
individuals with impaired baseline hearing had normal
baseline cognition so this cannot account for the findings.
Experimental evidence on whether hearing aid use
might alleviate some of these negative effects is not
available. Any intervention would require greater
complexity than merely suggesting to people that they use
a hearing aid because only a minority of people with
hearing loss are either diagnosed or treated,97 and when
hearing aids are prescribed many people do not use them.98
Central hearing loss is distinct from peripheral hearing
loss. It is a difficulty in understanding speech in noise
that is not explained by cochlear (peripheral) hearing
impairment and does not improve with peripheral
amplification (such as hearing aids).99 It is unlikely to be a
modifiable risk factor and could be a prodromal symptom
of Alzheimer’s disease causing impaired speech
perception, especially in the presence of competing
sounds.100 This theory is consistent with the fact that
central auditory areas are affected by Alzheimer’s disease
pathology.101 It is very unlikely that central hearing
impairment would account for the association between
peripheral hearing loss and dementia identified in
studies, because the central hearing loss that is followed
by Alzheimer’s disease is rare, at 2% of the older
population,100 while the prevalence of peripheral hearing
loss in the studies included in our meta-analysis in a
similar middle-aged and older population (mean ages in
the three included studies were 55 years, 64 years, and
75·5 years) is much larger (28%, 43%, and 58%,
depending on the specific study). Mild central hearing
loss might be more prevalent than the estimate of 2%, but
this has not been linked to increased risk of dementia.102
A small pilot intervention,103 Hearing Equality through
Accessible Research & Solutions (HEARS), used visual
materials and training for the participant and a family
member to increase usage of listening devices in
cognitively healthy adults with a mean age of 70 years.
The results of the pilot intervention showed that it might
be possible to increase their use.

Among the vascular risk factors, hypertension had the
highest preventable risk

Obesity is linked to pre-diabetes and metabolic syndrome which is characterised by insulin resistance and high
concentrations of peripheral insulin

It is thought that insulin resistance that can lead
to cerebral small vessel disease

Peripheral insulin anomalies are thought to cause a decrease in brain insulin production, which can impair amyloid clearance.

Both diabetes and high insulin levels have been associated with increased risk of developing Alzheimer disease, vascular dementia and cognitive decline.

Note - Metabolic syndrome is a cluster of conditions — increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels — that occur together, increasing your risk of heart disease, stroke and diabetes.

Older adults who exercise are more likely to maintain
cognition than those who do not exercise. No randomised
trials are available to show that exercise prevents cognitive
decline or dementia, but observational studies have found
an inverse relation between exercise and risk of dementia.
Results of one meta-analysis104 of 15 prospective cohort
studies following up 33816 individuals without dementia
for 1–12 years reported that physical activity had a
significant protective effect against cognitive decline, with
high levels of exercise being the most protective (hazard
ratio [HR] 0·62, 95% CI 0·54–0·70). Another metaanalysis105
included 16 studies with 163797 participants
without dementia and found that the RR of dementia in
the highest physical activity groups compared with the
lowest was 0·72 (95% CI 0·60–0·86) and the RR of
Alzheimer’s disease was 0·55 (95% CI 0·36–0·84).
Physical exercise leads to benefits in older people without
dementia, such as improving balance and reducing
falls,106 improving mood,107 reducing mortality, and
improving function.

The association with cognitive impairment might be due to the link between smoking and cardiovascular pathology, but cigarette smoke also contains neurotoxins which heighten the risk

Smoking had the third highest PAF, in keeping with
previous analyses.33 The association with cognitive impairment might be due to the link between smoking
and cardiovascular pathology, but cigarette smoke also
contains neurotoxins, which heighten the risk.112 Again,
its high prevalence contributes to the high PAF.
Interventions are being used to reduce cigarette smoking,
and smoking has and is declining in most countries;
although in 2015, smoking seemed to be increasing in
the eastern Mediterranean and Africa.113

Failing to seek early treatment for depression.

There is debate as to the direction of causation.

It is biologically plausible that depression increases dementia risk because it affects stress hormones, neuronal growth factors and hippocampal volume.


Depressive symptoms can be a part of the clinical
presentation of dementia, which has led to debate as to
the direction of causation: whether depression is a
prodromal symptom or an independent risk factor for
dementia. Cohort studies114 with longer follow-up times
show a link between number of depressive episodes and
risk of dementia, which strengthens the assertion that
depression is a risk factor for dementia. However, a
cohort study115 following people for up to 28 years before
the development of dementia found that it was only in
the 10 years before dementia incidence that depressive
symptoms were higher in people with dementia than
those without dementia. This suggests that midlife
depression is not a risk factor for dementia. However, it
remains unclear whether the high depressive symptoms
seen in people who go on to develop dementia are a
cause of dementia at a time of vulnerability or an early
symptom of dementia. It is biologically plausible that
depression increases dementia risk because it affects
stress hormones, neuronal growth factors, and hippocampal
volume.116 Antidepressant prescriptions have
increased in the past three decades and this increase is
hypothesised to affect dementia incidence since animal
data suggest that some antidepressants, including
citalopram, decrease amyloid production.117–119

Evidence is growing that social isolation is a risk factor for dementia and it increases the risk of hypertension coronary heart disease and depression.

Social isolation might also result in cognitive inactivity, which is linked to faster cognitive decline and low mood.

All these are risk factors for dementia themselves, which highlights the importance of considering the social engagement of older people and not only their physical and mental health.

Many of the things we've talked about relate to the course of a persons life.

However, the factors that possibly prevent dementia are the same factors needed to keep people with dementia well.