Q&A: PCPs ‘play critical role’ in preserving patients’ brain health

The number of Americans with dementia — which currently stands at 1 in 7 — could triple by 2050, according to an American Heart Association writing group.

The American Heart Association (AHA), with the support of the American Academy of Neurology, recently released “A Primary Care Agenda for Brain Health” in an effort to reduce that trend.

Ronald M. Lazar, PhD, FAHA, FAAN, a professor of neurology and director of the neuropsychology division at the University of Alabama at Birmingham, and colleagues wrote that preventing pathology-induced decline “is paramount, and primary care can play a critical role.”

In an interview with Healio Primary Care, Lazar discussed how primary care physicians and their colleagues can close the gap “between what primary care does in this area and what it can do.”

Healio Primary Care: What prompted the AHA to publish this scientific statement?

Lazar: It was established more than a decade ago that attention to certain lifestyle behaviors and risk factors, called “Life’s Simple 7,” can promote cardiovascular health. Since publication of the AHA/American Stroke Association presidential advisory on achieving optimal brain health in 2017, it has become apparent that we need to focus on these risk factors earlier in life.

Even in our 30s and 40s, when we are presumably in good health, the things we do — our behaviors and even how we monitor ourselves — can have a major impact on the integrity of our brain in later life. Our goal is to prevent or postpone cognitive decline before it happens.

Healio Primary Care: What can PCPs do to preserve brain health that they may not already be doing?

Lazar: There needs to be an explicit discussion between primary health care providers and their patients about how the factors described in our statement affect the brain and, in turn, cognition. PCPs are in the best position to promote overall health, including brain health, and to answer critical questions.

In addition to “Life’s Simple 7,” matters relating to sleep hygiene, stress, mood and even hearing need to be addressed. We recognize that the time for such conversations with a doctor is often limited in a visit to the office or clinic, so we have to take advantage of other clinicians, including advanced practice providers and health care counselors.

Much can be gleaned from the use of technology, including mobile devices, computers and even at the kiosk when patients check in at the clinic. For the implementation of this strategy, there are some challenges that need to be addressed, especially among disparate populations in which risk is often highest but access to health care and technology is limited. Messaging also needs to be understandable and culturally appropriate so patients can be health care partners with their providers.

Healio Primary Care: What evidence is there to suggest that the factors in the scientific statement help prevent cognitive decline?

Lazar: One of the best, recent demonstrations that modification of risk factors can prevent cognitive decline came from the SPRINT-MIND study, which was published in JAMA in 2019. As an ancillary to a larger investigation about optimal blood pressure management to prevent cardiovascular events, SPRINT-MIND showed that more intensive blood pressure control was significantly better than the AHA guidelines at the time in preventing the combined rate of mild cognitive impairment and dementia. Epidemiological studies have shown that smokers have an increased risk of dementia, smoking cessation decreases risk close to the level of never smokers, and that less physical activity is associated with higher risk for cognitive decline.

Healio Primary Care: How early should PCPs start discussing the factors described in the scientific statement?

Lazar: Primary care clinicians can uniquely target those modifiable risk factors that are prevalent at midlife but are known to exist as early as childhood. For example, according to the CDC, childhood obesity, a major risk factor for loss of brain health, is found in nearly 1 of 5 children in the United States. According to a 2018 AHA scientific statement, childhood obesity has risen in part because of sedentary behaviors in today’s youth, with school-aged children sedentary approximately 8 of their daily waking hours, much of which in front of a screen.

With respect to risk factors in adulthood, several population-based studies (ARIC and CARDia) have shown that blood pressure control in middle age more profoundly affects cognition at older age than blood pressure management in older age. The Insight 46 study reported in a 2019 Lancet article that high and increasing blood pressure among individuals around 40 years old were associated with structural brain changes at 69 to 71 years of age. Collectively, these data show that monitoring risk factors is a life-long endeavor.

References:

• AHA. 13 things primary care clinics can check to help preserve brain health. https://newsroom.heart.org/news/13-things-primary-care-clinics-can-check-to-help-preserve-brain-health. Accessed April 8, 2021.
• Lazar RM, et al. Stroke. 2021;doi:10.1161/STR.0000000000000367.