National Dementia Strategies: The Single Most Powerful Tool to Transform Dementia Care

According to the World Health Organization, there are currently around 50 million people worldwide living with dementia, with nearly 10 million new cases each year. By 2030, there will be an estimated 82 million people with dementia around the world, and 152 million by 2050. 

Dementia is one of the most common causes of disability among older adults, and has physical, psychological, social, and economic impacts on the individual, their caregivers, families, and society. As the prevalence of dementia increases, so do the costs and burdens associated with this illness. In fact, Chow et al (2018) reported that the total estimated global cost of dementia in 2015 was 818 billion USD, accounting for 1.09% of the world’s GDP. 

With the increasing incidence and impact of dementia on society, many countries around the world have developed a National Dementia Strategy as an official government policy to prioritize and carry out specific initiatives in order to better support individuals with dementia and their caregivers. Most recently, in 2017, Canada announced that it will become the 30^thcountry to adopt a national strategy for dementia. This past June 2019, the Canadian government published its first ever National Dementia Strategy.

In light of this recent development, our team examined the existing 29 strategies worldwide and published a review, “National Dementia Strategies: What Should Canada Learn?” in the Canadian Geriatrics Journal (Chow et al., 2018). We have included a portion of our review below, as it captures the heart of what a National Dementia Strategy is.

"In order to address this changing demographic, many countries are adopting a National Dementia Strategy (NDS) as a comprehensive government plan to provide appropriate medical care for people with dementia. A government dementia plan is a policy whereby the national government holds itself accountable to carry out its stated specific objectives and policy changes, although objectives can be accomplished with non-governmental collaborators... Created using input from various stakeholders (i.e., government agencies, legislators, residential and community care providers, professional and family carers, researchers, physicians, and people with dementia), the NDS is tailored specifically to the unique culture and demographics of each country to address a range of issues. Common priorities for NDSs include: raising awareness of the disease, combating stigma, identifying support services, quantifying the number of individuals with dementia, assessing and improving the quality of dementia care, and assessing the availability and access to diagnostic services. These strategies have been well-received and reported as the single most powerful tool to transform dementia care and support within a country."

In the coming months, we will be taking a deeper look at Canada’s newly developed National Dementia Strategy and what it means for Canadians living with dementia and their caregivers / families. We are looking forward to exploring this exciting area with you all soon!

For more information on the current statistics and incidence rates of dementia, please refer to the World Health Organization here: https://www.who.int/news-room/fact-sheets/detail/dementia

For our review on the 29 previously published National Dementia Strategies, please see: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6028171/

Welcome Back for our Fourth Year of the Dementia Awareness Program

This year marks the fourth year of our Dementia Awareness Program – a unique partnership led by Professor Nathan Herrmann and a group of high school students and alumni at Havergal College in Toronto, Canada. In September 2016, we created this program with the aim of raising awareness of and de-stigmatizing dementia both among our peers and school community, while also extending our work to the wider community. Since then, we have been fortunate to work closely with and be mentored by Professor Herrmann – the Richard Lewar Chair in Geriatric Psychiatry at Sunnybrook Health Sciences Centre and the University of Toronto.

With our vision to champion dementia, the Dementia Awareness Programprovides students the opportunity to enrich the lives of seniors with dementia. Each week, our two student leaders coordinate a group of dedicated volunteers to visit a local seniors’ residence, where each student is paired up with an individual with dementia. As we gain first-hand experience working with people with dementia, we have taken the initiative to share what we have learned about dementia and the current research in the field on our blog throughout the past three years. We are proud to be international ambassadors for dementia by increasing awareness of this important illness via our blog, which has received over 3,500 visits from readers all over the world.

We are looking forward to continuing the Dementia Awareness Program this school year through both our blog here and the community partnership between Havergal College students and a local seniors’ residence. 

Our monthly blog series this year will shine a spotlight on the community by raising awareness of the resources and support available for dementia patients and caregivers from Canadian organizations and the government. In particular, we will be featuring Canada’s recently published National Dementia Strategy, along with national organizations dedicated to helping patients and their families through research, healthcare delivery, education and/or advocacy.

We hope that you are as excited as we are to explore the resources and support available in the community for individuals and families affected by dementia. Together, we can work to restore some of what dementia takes away.

You can also follow Professor Herrmann’s “Memory Doctor” blog for dementia caregivers at: http://health.sunnybrook.ca/memory-doctor/

Professor Nathan Herrmann and Student Executive Team

Chair               Selina Chow

Vice-Chair       Sae Furukawa

Vice-Chair       Katie Taub

Nathan Herrmann MD FRCPC

Professor, Faculty of Medicine, University of Toronto

Lewar Chair, Geriatric Psychiatry

Head, Division of Geriatric Psychiatry

Sunnybrook Health Sciences Centre

Concluding Remarks from Professor Nathan Herrmann and Student Executive Team

This year marks the third year of successfully running the Dementia Awareness Program at Havergal College. An enthusiastic group of 8 new and experienced student volunteers and 2 dedicated advisors travelled to Briton House retirement home in Toronto weekly on Wednesdays to visit residents with dementia. Each week, our volunteers meet with various residents and played card games, did puzzles, had conversations, and enjoyed each other’s company. The residents certainly seemed to enjoy and look forward to our visits, as did our student volunteers. The student volunteers learned a lot by improving their communication and problem solving skills all while having fun and forming intergenerational relationships. 

A highlight of this year was our music performances! Our student volunteers performed various songs accompanied by our teacher advisor on the keyboard. Even though we were not the best of singers, the residents greatly enjoyed our performance and many stopped to listen, clap and even sing along. We even met with a former Havergal graduate and her son who stopped by to introduce themselves after our performance! 

On behalf of the Dementia Awareness Program, we would like to thank all of our student volunteers for their dedication to this program. We would also like to thank our staff advisors from Havergal College for their continual support. Finally, thank you to the staff at Briton House for allowing us to visit weekly and for all of their support in this partnership. 

To our readers, thank you for following our monthly blog series this year, and we hope that you have been able to learn more about the exciting new research surrounding dementia, as well as getting to know some of the prominent local female scientists in this field through our researcher profiles. We would like to sincerely thank Dr. Herrmann for his continued support and guidance over the program and this blog. Additionally, we would like to thank him for connecting us with the researchers and scientists featured in our researcher profiles – who have inspired and taught us so much about the importance and need for dementia research. For more information on dementia, you can also follow Dr. Herrmann’s “Memory Doctor” blog for dementia caregivers at: http://health.sunnybrook.ca/memory-doctor/

On behalf of all the Havergal College students involved in this program, thank you for your continued support and engagement with the Dementia Awareness Program. We look forward to another successful year of the Dementia Awareness Program next year, as we continue to raise awareness of this illness and visit individuals with dementia weekly to engage them in meaningful interactions. 

Professor Nathan Herrmann and Student Executive Team

Chair                Selina Chow

Vice-Chair        Clarissa Yu

Vice-Chair        Olivia Nadalini

Nathan Herrmann MD FRCPC

Professor, Faculty of Medicine, University of Toronto

Lewar Chair, Geriatric Psychiatry

Head, Division of Geriatric Psychiatry

Sunnybrook Health Sciences Centre

Featured Researcher: Professor Paula Rochon

Dr. Paula Rochon is a geriatrician who is recognized for her work to focusing on dementia management of older adults, especially women. She is a senior scientist and the vice-president of research at Women’s College Hospital. Dr. Rochon leads Women’s Xchange, a research and exchange centre focussing on improving women’s health. She is also a professor at the University of Toronto in the Department of Medicine and Institute of Health Policy Management and Evaluation.  

We were fortunate to be able to interview Dr. Rochon about her work and ask her questions about her work.  

1. What brought up the issue of a need for dementia management research for different sexes?

It is important to consider sex and gender dimensions in all research because these factors serve an important role in affecting a patient’s health, their risk factors, how they experience health care and how health-care professionals provide care. When research studies do not report differences between women and men, we are left with a less valuable view of best practices for proper prescribing techniques, effective treatment methods and outcomes. Research that incorporates and reports data reflective of the whole population benefits everyone. As the Lead of Women’s Xchange, a knowledge translation and exchange centre based at Women's College Hospital designed to promote the development of women's health research across the province, it is a priority for myself and my team to reinforce the need to integrate sex and gender into research. With regards to dementia specifically, it is a condition that disproportionately impacts women. The burden of caregiving also falls more heavily on women, who are more likely to provide care for a parent, relative or spouse with dementia.

2. How is the care for older women with dementia different from men? What are some ways to improve the quality of care of different sexes?

Some of the work that we have done suggests that women are prescribed slightly lower doses of dementia medications relative to men. This may be because women require a lower dose to reduce the development of adverse events. Women generally live longer than men, which means that more women are living alone and may not have someone to provide care for them. This may explain in part why there are substantially more women than men in long-term care homes.

3. How have you seen the treatment of older adults improve over the years?

Over the years, there has been a growing recognition surrounding the importance of sex and gender considerations in research. Having better evidence that is tailored to women and men will result in better treatment for all Canadians. The inclusion of a sex-and-gender lens in health research creates evidence-based, effective and appropriate health-care policies for all.

4. What is the most important factor in improving the care of older adults with dementia?

Many older adults want to remain in their homes.  For this to happen, we need a lot more support in the community, particularly when it comes to caregivers. Caregiving has become increasingly taxing as many untrained people are providing medical and nursing care, assisting with daily living, and navigating the complexities of the health and long-term care system. As well, caregivers often provide financial support to their loved ones and may miss out on full-time employment, raises and other monetary benefits. Improving care for older adults with dementia starts with our caregivers.

5. What are prescribing cascades? What would you suggest doing to improve the issue of prescribing cascades?  

Prescribing cascades occur when a drug therapy leads to an adverse event that is misinterpreted as a new medical condition. This leads to the prescribing of a new drug therapy that may not be required. Prescribing cascades are particularly common in older adults, in part because they are a group that have more medical conditions and therefore may be prescribed more drug therapies. Prescribing cascades have also been identified with the drug therapies that are frequently used to manage dementia. One example is cholinesterase inhibitors, leading to incontinence, leading to the new prescription for a urinary anticholinergic.

 For more information on recognizing and managing prescribing cascades, you can access an article I co-wrote in the Lancet.

Research Update: Cognitive Impairments Reversed in Mice with Dementia

In hopes of finding effective treatments and possibly even a cure for dementia, scientists have been searching for ways to reverse memory deficits and impairments. For many years, advances in this area was challenging due to little knowledge about the cellular pathways which underlie dementia. However, promising research emerged in June 2018 when researchers at the Lewis Katz School of Medicine at Temple University were able to reverse cognitive impairments in mice with dementia. 

The study, published in the journal Molecular Neurobiology, showed for the first time in an animal model, that a drug can reverse tau pathology – the second-most important brain lesion in dementia patients. As senior investigator Dr. Domenico Praticò explains, “We show that we can intervene after disease is established and pharmacologically rescue mice that have tau-induced memory deficits.” 

The researchers discovered that dementia is related to damage to nerve cells from inflammatory molecules known as leukotrienes. The team then aimed to test if blocking leukotrienes could reverse the cognitive impairment in mice with dementia. This was done by injecting the mice with zileuton – a drug that inhibits the formation of leukotriene by blocking the 5-lipoxygenase enzyme. 

At the end of the 16-week treatment period, the mice were put into maze tests to assess their working and spatial learning memory. In comparison to the untreated animals, the tau mice that were injected with zileuton performed significantly better, suggesting that zileuton successfully reversed the cognitive impairment. 

In fact, the researchers found a 90% reduction in leukotrienes in the treated mice compared to the untreated group. As well, levels of phosphorylated and insoluble tau decreased by 50% in treated animals. Insoluble tau is known to directly damage synapses; thus, microscopic examination revealed severe synaptic deterioration in the untreated animals, while the synapses of the treated mice appeared to be undamaged. As said by Dr. Praticò, “Inflammation was completely gone from tau mice treated with the drug. The therapy shut down inflammatory processes in the brain, allowing the tau damage to be reversed.” 

More information on the study conducted by the team at the Lewis Katz School of Medicine at Temple University can be found here: https://www.sciencedaily.com/releases/2018/06/180608101905.htm

Featured Researcher: Professor Sandra Black

Professor Sandra Black is a world-renowned physician and researcher recognized for her work in dementia and stroke diagnosis and treatment. She is a University of Toronto Professor of Neurology, and a senior scientist and program director of the Hurvitz Brain Sciences Research Program at the Sunnybrook Research Institute. Professor Black is also the executive director of the Toronto Dementia Research Alliance (TDRA), and held the inaugural Deborah Ivy Christian Brill Chair in Neurology at Sunnybrook Health Sciences Center and University of Toronto (2006-2017). In 2015, she was appointed as an Officer to the Order of Canada for her contributions to stroke and dementia research. Professor Black is internationally recognized particularly for work showing relationships between silent stroke and Alzheimer’s Disease. 

We were fortunate to interview Professor Black and ask her questions about her research. 

What is the most rewarding part of being a researcher? 

One of the most rewarding aspects of being a researcher for Dr. Black is to be on the front line of new treatments and discoveries. For example, she does clinical trials, some sponsored by drug companies to test out new treatments for dementia, and some to repurpose existing drugs when they may be potentially useful in another disease, for which they were not initially intended. For example, some high blood pressure medications may be preferable for hypertensive Alzheimer’s Disease (AD) patients, so Dr Black is conducting a trial to compare the effectiveness of two commonly use blood pressure drugs that are equally good for hypertension control in slowing down brain shrinkage in AD. Dr. Black explained that as a researcher, you are always learning and collaborating with others to help understand mechanisms and improve care. She finds it rewarding to be able to “give back” adding new knowledge to the field and sharing it with others. 

What is your latest research study about dementia? 

Dr. Black is very optimistic about the future of dementia research and research for other mental and neurological conditions. She describes it as a very “interesting era” and an “exciting time” in dementia research. She is currently involved in a clinical trial that is investigating how to remove and slow amyloid protein depositing in the brain in people before they have any memory symptoms. Participants come in for a monthly infusion aimed at removing amyloid protein from the brain and preventing its accumulation, which can eventually lead to memory loss and dementia. It is a double –blind controlled trial meaning patients are randomized to active drug or placebo without anyone knowing which drug they are on, unless of course some problem arises.

How have you seen dementia treatment and research evolve in your years of working as a researcher? 

At the beginning, Dr. Black explained how the focus of research was on learning the causes and components of the dementing illness, examining the proteins in the brain, and investigating the pathology. However, as the disease has become increasingly prevalent with an aging population, research and treatment has intensified and advanced. Dr. Black in collaboration with other research colleagues and radiologists helped developed an MRI protocol in her clinic long ago which allowed them to scan the brain and quantify brain shrinkage and also small vessel disease, which shows up as small strokes or as white spots and patches on MRI scans. Additionally, she has been involved in researching the genetic and hereditary side to dementia. There have also been advancements in using PET scans to see protein deposits in the brain that previously were only able to be seen at autopsy. Now, there is also research into vascular risk factors and lifestyle choices that contribute to the development of Alzheimer’s disease and stroke. For example, hypertension control is important for preventing dementia developing, and a history of a high level of physical exercise especially in teen age and through all the decades of life was found to be associated with better performance on cognitive tests, when those same people were assessed in their 80s. 

Congratulations on receiving the Order of Canada for your research! Have you seen your research impact the way that dementia is diagnosed and treated? 

Dr. Black explained that in the past, dementia research had been focused primarily on the amyloid protein, which deposits in the brain and can be associated with dementia. However, coming from a research background in stroke and dementia, Dr. Black wanted to better understand the role of other factors, such as the brain’s blood vessels, in developing dementia. She began to explore how the brain builds resilience and tries to combat the gradual loss of functional neural networks in neurodegenerative diseases such as Alzheimer’s by careful quantitative assessments of clinical and brain imaging in a research partnership with her memory clinic patients, also including genetics, and her team’s findings have influenced other research and treatment approaches earning her the well-deserved appointment to the Order of Canada. 

            

Read more about Professor Black’s work:

 https://sunnybrook.ca/research/team/member.asp?t=10&m=28&page=1212

Research Update: Slowed Brainwaves are Early Signs of Dementia

To catch dementia and Alzheimer’s disease early on, scientists are looking for effective signs to use to diagnose dementia earlier. According to recent findings from researchers at the University of Toronto and Baycrest Rotman Research Institute, tracking a person’s brainwave activity can give clues of early signs of dementia.

The study examined the electrical activity and brain structures of 64 adults when they were in a resting state. Magnetoencephaolography (MEG) was used to measure brainwaves and their location, and magnetic resonance imaging (MRI) was employed to determine the magnitude of loss of brain cells. The participants were also evaluated for their cognitive abilities. 

The study, published in the journal Human Brain Mapping, suggested that brainwave activity tends to slow down in certain brain regions that are likely to be affected by dementia next. The team of researchers identified slowed brainwaves and subtle signs of damage in the brain areas in charge of memory and planning, in both individuals with mild cognitive impairment and those with primary progressive aphasia – a rare form of language dementia. Although these individuals were only observed to display minor memory and thinking problems, their slowing brainwaves predicted the severity of their cognitive impairment, including the degree of memory loss.

Jed Meltzer, the senior author of the study and Canada Research Chair in Interventional Cognitive Neuroscience, explains that, “By using brain imaging, we were able to pinpoint that this slowing of electrical activity occurs in specific regions that have not yet lost brain cells, but are negatively affected by the disease. This means that these areas could be more responsive to treatments since the brain cells have not died yet and are only starting to undergo damage.” In essence, slowed brainwaves can act as a sign of when brain cells begin to malfunction and may allow for new targeted brain treatments to be implemented early on.

The team aims to continue exploring and validating the use of brain activity as a reliable biomarker for early signs of dementia. More information about this study can be found here: https://www.utoronto.ca/news/u-t-study-links-slowed-brainwaves-early-signs-dementia