Dementia prevention, intervention, and care

this report, we have summarised what should be done now, and when the available evidence is not definitive, we have made this clear.We have itemised interventions which can transform the lives of people with dementia and their families, maximising cognition, decreasing distressing associated symptoms, reducing crises and improving quality of life.Timely diagnosis is a prerequisite to receiving these interventions.We are interested in what works and have included pharmacological, psychological, environmental and social interventions.If these are implemented, people with dementia will have their cognition optimised and be less likely to be agitated, depressed or have troublesome psychotic symptoms and family carers will have reduced levels of anxiety and depression.It is also important to discuss future decision-making as soon as possible with people with dementia and allow them to nominate an agent who can enact pre-specified wishes or make choices consistent with their values.People with dementia are usually older, often have co-morbidities and may need help in coping with these illnesses.A third of older people now die with dementia and all professionals working in endof-life care need to make this a central part of their planning and communication.In this commission, we have detailed evidence-based approaches to dementia and its symptoms.Services should be available, scalable and give value.As there are limited resources, professionals and services need to use what works, not use what is ineffective, and be aware of the difference.Overall, there is good potential for prevention and, once someone develops dementia, for care to be high-quality, accessible, and give value to an under-served, growing population.Effective dementia prevention and care could transform the future for society and vastly improve living and dying for individuals with dementia and their families.Acting now on what we already know can make this difference happen. Key Messages1 There are increasing numbers of people with dementia globally although incidence in some countries has decreased.2 Be ambitious about prevention: We recommend energetically treating hypertension in middle aged and older people without dementia to reduce dementia incidence.Interventions for other risk factors, including more childhood education, exercise, maintaining social engagement, reducing smoking, and management of hearing loss, depression, diabetes and obesity; may have the potential of delaying or preventing a third of dementias. Treat cognitive symptoms:To maximise cognition, people with Alzheimer's dementia or Dementia with Lewy Bodies should be offered Cholinesterase Inhibitors (ChEIs)at all stages, or memantine for severe dementia.ChEIs are not effective in Mild Cognitive Impairment. 4 Individualise dementia care: Good dementia care spans medical, social and supportive care, should be tailored to unique individual and cultural needs, preferences, priorities, and should incorporate support for the family carers 5 Care for family carers.Family carers are at high risk of depression.Effective interventions reduce the risk and treat the symptoms, include START (Strategies for Relatives) or REACH (Resources for Enhancing Alzheimer's Caregiver Health intervention) and should be made available.6 Plan for the future.People with dementia and their families value discussions about the future and decisions about possible attorneys to make decisions.Clinicians should consider capacity to make different types of decisions at diagnosis.7 Protect people with dementia.People with dementia and society require protection from possible risks of the condition, including self-neglect, vulnerability including to exploitation, managing money, driving or using weapons.Risk assessment and management at all stages of the disease is essential but it should be balanced against the persons' right to autonomy.8 Manage neuropsychiatric symptoms.Management of the neuropsychiatric symptoms of dementia including agitation, low mood or psychosis, is usually psychological, social, and environmental, with pharmacological management reserved for those with more severe symptoms.9 Consider end of life.A third of older people die with dementia, so it is essential that professionals working in end-of-life care consider whether a patient has dementia as they may be unable to make decisions about their care and treatment or express their needs and wishes.10 Technology: Technological interventions have the potential to improve care delivery but should not replace social contact. Key points and recommendationsGroup CST improves cognition in patients with mild-to-moderate dementia.It is unclear whether the active component is cognitive or social as individual CST is ineffective or whether the effect size is clinically-significant.Individual cognitive rehabilitation can be effective for patients with mild-tomoderate dementia with specific functional goals, but its cost-effectiveness requires more evidence.