Increasing awareness for dementia risk reduction through a public awareness campaign in Denmark: A pre-post study.

OBJECTIVE: It is estimated that about 40% of all dementia cases are potentially attributable to modifiable risk factors, but awareness of this is relatively lacking. METHODS: An 18-months nation-wide public awareness campaign on dementia risk reduction was rolled out in Denmark that combined a mass-media approach with an online risk assessment tool and knowledge bank targeting all inhabitants aged between 40 and 75 years. Campaign effects (increase in awareness and knowledge of modifiable dementia risk and protective factors) were assessed via online surveys in two independent random samples before (n = 1003) and after the campaign (n = 1076). RESULTS: After adjusting for differences in educational level between the two samples, there was no significant difference in awareness of dementia risk reduction between the pre-campaign (66.5% aware) and post-campaign (63.4% aware) sample (probit z = -0.08, p = 0.151). The number of correctly identified risk/protective factors was significantly higher in the post-campaign sample. After adjusting for potential confounding factors, self-reported exposure to the campaign was associated with more awareness, better recognition of risk/protective factors, more motivation for and actual implementation of lifestyle changes. CONCLUSIONS: This mass-media campaign did not increase overall awareness that dementia risk is partly modifiable. However, exposure to the campaign was associated with more awareness and willingness to take action to improve brain health. Future campaigns should tailor messages to specific subgroups to broaden the reach (e.g., males), co-create materials with the target group, and give special attention to the contribution of metabolic/cardiovascular risk factors to dementia risk.

Associations of an individual's need for cognition with structural brain damage and cognitive functioning/impairment: cross-sectional population-based study.

BACKGROUND: High cognitive activity possibly reduces the risk of cognitive decline and dementia. AIMS: To investigate associations between an individual's need to engage in cognitively stimulating activities (need for cognition, NFC) and structural brain damage and cognitive functioning in the Dutch general population with and without existing cognitive impairment. METHOD: Cross-sectional data were used from the population-based cohort of the Maastricht Study. NFC was measured using the Need For Cognition Scale. Cognitive functioning was tested in three domains: verbal memory, information processing speed, and executive functioning and attention. Values 1.5 s.d. below the mean were defined as cognitive impairment. Standardised volumes of white matter hyperintensities (WMH), cerebrospinal fluid (CSF) and presence of cerebral small vessel disease (CSVD) were derived from 3T magnetic resonance imaging. Multiple linear and binary logistic regression analyses were used adjusted for demographic, somatic and lifestyle factors. RESULTS: Participants (n = 4209; mean age 59.06 years, s.d. = 8.58; 50.1% women) with higher NFC scores had higher overall cognition scores (B = 0.21, 95% CI 0.17-0.26, P < 0.001) and lower odds for CSVD (OR = 0.74, 95% CI 0.60-0.91, P = 0.005) and cognitive impairment (OR = 0.60, 95% CI 0.48-0.76, P < 0.001) after adjustment for demographic, somatic and lifestyle factors. The association between NFC score and cognitive functioning was similar for individuals with and without prevalent cognitive impairment. We found no significant association between NFC and WMH or CSF volumes. CONCLUSIONS: A high need to engage in cognitively stimulating activities is associated with better cognitive functioning and less presence of CSVD and cognitive impairment. This suggests that, in middle-aged individuals, motivation to engage in cognitively stimulating activities may be an opportunity to improve brain health.

Older adults' awareness of modifiable risk and protective factors for dementia and interest in eHealth interventions for brain health: a comparison between the Netherlands and Germany.

BACKGROUND: Evidence on modifiable risk factors for dementia is accumulating rapidly, including e.g. smoking, hypertension, and diabetes. Comparing knowledge of risk factors for dementia and factors associated with knowledge and motivation to learn about dementia risk reduction in different countries may support the design of tailored public health campaigns. We investigated (1) differences in knowledge of risk and protective factors for dementia between the Netherlands and Germany, and interest in (2) information on brain health and (3) eHealth for brain health. MATERIALS AND METHODS: Population-based telephone (Germany) or web-based surveys (Netherlands) were conducted among adults aged 60-75 (ntotal=614; Germany: n = 270; Netherlands: n = 344), assessing sociodemographic factors, knowledge of risk and protective factors for dementia, interest in information on brain health and respective eHealth-tools. Correlates of knowledge, interest in information on brain health and eHealth for brain health were analyzed using multivariable regression, by country and in pooled analyses. RESULTS: In the total sample (Mage: 67.3 (SD: 4.3) years; %female: 48.6), knowledge of risk and protective factors (sum score assessing number of correctly identified factors) was higher among German participants (M (SD) = 7.6 (2.5) vs. 6.0 (4.3), p < .001). This was confirmed using linear regression analyses, controlling for sociodemographic covariates (b = 1.51; 95% CI: 1.00; 2.01). High education was linked to better knowledge of risk and protective factors (b = 1.61; 95% CI: 0.89; 2.34). Controlling for covariates, interest in information on brain health (OR: 0.05, 95% CI: 0.02; 0.09) and eHealth for brain health (OR: 0.40, 95% CI: 0.25; 0.65) was lower in German participants. Widowed participants were less interested in information on brain health, while widowed and single participants expressed less interest in eHealth for brain health in pooled analyses. Further associations between sociodemographic factors, interest in information on brain health and eHealth for brain health by country were detected. DISCUSSION: Engaging older adults in the design of eHealth interventions and cooperation with trusted sources, e.g., general practitioners, might enhance appreciation of eHealth for brain health. Education on risk and protective factors for dementia is warranted in both countries. However, differences in recruitment and assessment need to be acknowledged.

Socioeconomic position, modifiable dementia risk and cognitive decline: results of 12-year Maastricht Aging Study.

OBJECTIVES: This study investigated whether the association between modifiable dementia risk and rate of cognitive decline differs across socioeconomic status (SES) strata. DESIGN, SETTING AND PARTICIPANTS: Data were used from Maastricht Aging Study, a prospective cohort study with a 12-year follow-up. The baseline sample consisted of 1023 adults over 40 years old. MEASUREMENTS: The "LIfestyle for BRAin health" (LIBRA) index was used to assess modifiable dementia risk. Cognitive performance was assessed at baseline, 6 and 12 years, and measured in the domains of information processing speed, executive functioning and verbal memory function. An SES score was calculated from equivalent income and educational level (tertiles). Linear mixed models were used to study the association between LIBRA, SES and their interaction on the rate of cognitive decline. RESULTS: Participants in the lowest SES tertile displayed more decline in information processing speed (vs. middle SES: X2 = 7.08, P = 0.029; vs. high SES: X2 = 9.49, P = 0.009) and verbal memory (vs. middle SES: X2 = 9.28, P < 0.001; vs. high SES: X2 = 16.68, P < 0.001) over 6 years compared to their middle- and high-SES counterparts. Higher (unhealthier) LIBRA scores were associated with more decline in information processing speed (X2 = 12.66, P = 0.002) over 12 years and verbal memory (X2 = 4.63, P = 0.032) over 6 years. No consistent effect modification by SES on the association between LIBRA and cognition was found. CONCLUSIONS: Results suggest that lifestyle is an important determinant of cognitive decline across SES groups. Yet, people with low SES had a more unfavorable modifiable risk score suggesting more potential for lifestyle-based interventions.

Public Perspectives on Lifestyle-Related Behavior Change for Dementia Risk Reduction: An Exploratory Qualitative Study in The Netherlands.

BACKGROUND: There is accumulating evidence that addressing modifiable risk and protective factors has an impact on dementia rates. Insight into the public's perspectives on dementia risk reduction is needed to inform future individual-level interventions and public health approaches. OBJECTIVE: This study explores the publics' openness towards dementia risk reduction and willingness towards changing lifestyle behavior to reduce the future risk for dementia. METHODS: Using a screening questionnaire, participants were purposively selected based on lifestyle behaviors that are associated with dementia risk. One-on-one interviews were used to explore their openness towards dementia risk reduction and willingness towards behavior change. Independently, two researchers performed an inductive content analysis. RESULTS: Interviews were conducted with 23 participants aged from 40 to 79 years. Main themes that were identified from the data were: 1) abstractness of dementia risk reduction, 2) ambivalence towards changing behavior, 3) negative self-image and low behavioral control, and 4) all-or-nothing thinking about lifestyle change. CONCLUSIONS: The concept of dementia risk reduction seems difficult to translate to the personal context, particularly if individuals perceive that dementia would occur decades in the future. This is problematic because a large proportion of the public needs a healthier lifestyle to reduce the incidence of dementia. Translating healthy intentions into behavior is complex and involves overcoming a variety of barriers that complicate dementia risk reduction initiatives. Support is needed for individuals who experience additional obstacles that obstruct commencing to a healthier lifestyle (e.g., negative self-image, engaging in multiple unhealthy behaviors, unrealistic perceptions about lifestyle change).

Using mHealth for Primary Prevention of Dementia: A Proof-of-Concept Study on Usage Patterns, Appreciation, and Beliefs and Attitudes Regarding Prevention.

BACKGROUND: Health- and lifestyle factors account for a substantial part of all dementia cases, which opens the opportunity for primary prevention. However, the required behavioral change is complex and involves targeting multiple risk factors. mHealth interventions can potentially contribute to improving motivation in a low-cost and scalable way. OBJECTIVE: To explore usage patterns, appreciation, and beliefs and attitudes regarding dementia risk reduction during the use of the MyBraincoach mobile app. METHODS: Participants were community-dwelling middle-aged adults from the Netherlands and used either the standard (education) or extended (education+motivational triggers) app version for three months. Two panel studies were combined in this paper. Chi-square tests, t-tests and linear mixed models were used, adjusted for age, sex, and education. RESULTS: Of all participants (n = 299, 50.2% male), 167 (55.9%) had installed the app. The most reported reason for non-use was technical problems (47%). Those who used the app were at baseline already more positive about dementia risk reduction than those who did not use the app. Of all users who completed the evaluation (n = 102), 78.4% (n = 80) stated that the app provided a positive approach towards brain health and 80.4% (n = 82) felt better informed. Younger (<60y) and lower educated participants evaluated the app most positively. CONCLUSION: Usage of the app was low, but users showed more positive beliefs and attitudes regarding dementia risk reduction. Most users evaluated the app positively and stated to have gained knowledge on the topic. Improving the use of the app must keep high priority in future studies.

Protocol for a pre-post, mixed-methods feasibility study of the Brain Bootcamp behaviour change intervention to promote healthy brain ageing in older adults.

INTRODUCTION: Behaviour change interventions represent key means for supporting healthy ageing and reducing dementia risk yet brief, scalable behaviour change interventions targeting dementia risk reduction in older adults is currently lacking. Here we describe the aims and design of the three-month Brain Bootcamp initiative that seeks to target multiple dementia risk and protective factors (healthy eating, physical, social and cognitive inactivity), through the use of multiple behaviour change techniques, including goal-setting for behaviour, information about health consequences and physical prompts to change behaviours that reduce dementia risk among older adults. Our secondary aim is to understand participants' views of dementia prevention and explore the acceptability and integration of this campaign into daily life. METHODS: Brain Bootcamp is a pre-post feasibility trial conducted in Sydney, Australia beginning in January 2021 until late August. Participants aged ≥65 years living independently in the community (n = 252), recruited through social media and flyers, will provide information about their demographics, medical history, alcohol consumption, smoking habits, mental health, physical activity, cognitive activity, and diet to generate a dementia risk profile at baseline and assess change therein at three-month follow-up. During the intervention, participants will receive a resource pack containing their individual risk profile, educational booklet on dementia risk factors and four physical items designed to prompt physical, social and mental activity, and better nutrition. Outcome measures include change in dementia risk scores, dementia awareness and motivation. A qualitative process evaluation will interview a sample of participants on the acceptability and feasibility of the intervention. DISCUSSION: This will be the first short-term multi-domain intervention targeting dementia risk reduction in older adults. Findings will generate a new evidence base on how to best support efforts targeting lifestyle changes and to identify ways to optimise acceptability and effectiveness towards brain health for older adults. TRIAL REGISTRATION NUMBER: ACTRN 381046 (registered 17/02/2021); Pre-results.

[Raising awareness for dementia risk reduction through a public health campaign: a pre-post study]. / Een publiekscampagne om bewustwording over risicoreductie van dementie te verhogen: een pre-post studie.

This study evaluates a public health campaign initiated by the Alzheimer Center Limburg of Maastricht University. The aim was to increase awareness of the influence of a healthy lifestyle on lowering the risk of dementia in community-dwelling inhabitants of the Province of Limburg (aged 40 - 75 years). The campaign used mass media and public events, supported by a campaign website and mobile application (MijnBreincoach app).  An additional district-oriented approach was chosen in the municipalities of Roermond, Landgraaf and Brunssum, in which local stakeholders were involved in the design and execution of campaign-related events. Population-level difference in awareness before and after the campaign was assessed in two independent samples. No pre-post difference was observed in the level of awareness of dementia risk reduction. An additional analyses in the post-campaign sample revealed that the group that reported to have heard of the campaign, was more often aware of dementia risk reduction and reported higher motivation for behavioural change than the group that had not heard of the campaign. The district-oriented approach resulted in better recognition of campaign-material and the mobile application. With regard to the individual lifestyle factors, healthy diet and physical activity were identified more often post-campaign. Cognitive activity was identified most often at both pre- and post-assessment, but there was no increase in awareness after the campaign.

Associations of the Lifestyle for Brain Health Index With Structural Brain Changes and Cognition: Results From the Maastricht Study.

BACKGROUND AND OBJECTIVES: Observational research has shown that a substantial proportion of all dementia cases worldwide are attributable to modifiable risk factors. Dementia risk scores might be useful to identify high-risk individuals and monitor treatment adherence. The objective of this study was to investigate whether a dementia risk score, the Lifestyle for Brain Health (LIBRA) index, is associated with MRI markers and cognitive functioning/impairment in the general population. METHODS: Cross-sectional data were used from the observational population-based cohort of The Maastricht Study. The weighted compound score of LIBRA (including 12 dementia risk and protective factors, e.g., hypertension, physical inactivity) was calculated, with higher scores indicating higher dementia risk. Standardized volumes of white matter, gray matter, and CSF (as proxy for general brain atrophy), white matter hyperintensities, and presence of cerebral small vessel disease were derived from 3T MRI. Cognitive functioning was tested in 3 domains: memory, information processing speed, and executive function and attention. Values ≤1.5 SDs below the average were defined as cognitive impairment. Multiple regression analyses and structural equation modeling were used, adjusted for age, sex, education, intracranial volume, and type 2 diabetes. RESULTS: Participants (n = 4,164; mean age 59 years; 49.7% men) with higher LIBRA scores (mean 1.19, range -2.7 to 9.2), denoting higher dementia risk, had higher volumes of white matter hyperintensities (ß = 0.051, p = 0.002) and lower scores on information processing speed (ß = -0.067, p = 0.001) and executive function and attention (ß = -0.065, p = 0.004). Only in men, associations between LIBRA score and volumes of gray matter (ß = -0.093, p < 0.001) and CSF (ß = 0.104, p < 0.001) and memory (ß = -0.054, p = 0.026) were found. White matter hyperintensities and CSF volume partly mediated the association between LIBRA score and cognition. DISCUSSION: Higher health- and lifestyle-based dementia risk is associated with markers of general brain atrophy, cerebrovascular pathology, and worse cognition, suggesting that LIBRA meaningfully summarizes individual lifestyle-related brain health. Improving LIBRA factors on an individual level might improve population brain health. Sex differences in lifestyle-related pathology and cognition need to be further explored. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that higher LIBRA scores are significantly associated with lower scores in some cognitive domains and a higher risk of cognitive impairment.

Increasing knowledge on dementia risk reduction in the general population: Results of a public awareness campaign.

Strategies to reduce dementia risk are needed to minimize the burden of this growing public health concern. Most individuals are not aware that dementia risk reduction is possible, let alone how this could be achieved. Health education, such as public awareness campaigns on the topic of dementia risk reduction, can meet this need. A public health campaign (including social media and offering an online individual risk assessment tool) was carried out over a 7-month period in Flanders, Belgium. Impact was assessed in two independent online surveys, before (n = 1003) and after the campaign (n = 1008), in representative samples of adults aged 40-75 years. Questions regarding personal needs, wishes and barriers were also included. After the campaign, more individuals (10.3%) were aware that dementia risk reduction is possible than before the campaign, and more individuals correctly identified 10 out of 12 surveyed modifiable dementia risk and protective factors. However, no differences were observed in low-educated individuals. Further, specific differences in potential needs, wishes and barriers for future campaigns or interventions were observed between demographic strata. The majority of the respondents (89%) indicated that they would welcome more information on improving their brain-health. More than half (54%) also believed that they lacked the necessary knowledge to make brain-healthy behavior changes. In conclusion, effective public awareness campaigns on the topic of dementia risk reduction are feasible and timely, given the state of the evidence. Special efforts need to be made to develop effective campaigns, tailored towards low-educated individuals.

Raising awareness for dementia risk reduction through a public health campaign: a pre-post study.

OBJECTIVES: Evaluate the effect of a health promotion campaign aimed at increasing awareness about dementia risk reduction in middle-aged community-dwelling individuals in the Netherlands. DESIGN: A 10-month public health campaign using mass media and community participation, supported by eHealth. Population-level difference in awareness before and after the campaign, including variation between demographic groups, was assessed in two independent cross-sectional samples from the same target population. SETTING: The public health campaign was launched in the Province of Limburg, the Netherlands, targeting all inhabitants aged 40-75 years old. Three specific districts within the Province were chosen for an additional community participation approach, in which local stakeholders were invited to support the campaign. RESULTS: No pre- (n=590) post- (n=602) difference was observed in people agreeing to the statement that dementia risk reduction is possible (X2(1)=1.27, p=0.260). For the individual lifestyle factors, physical activity (7.6% increase (X2(1)=7.48, p=0.006)) and healthy diet (10.5% increase (X2(1)=12.37, p≤0.001)) were identified more often as being protective against dementia after the campaign. Of all risk/protective factors assessed, cognitive activity was identified most often at both preassessment (79.4%) and postassessment (80.4%), but there was no increase in awareness (X2(1)=0.17, p=0.677). Self-reported exposure to the campaign was associated with greater awareness and motivation for behavioural change (X2(1)=6.52, p=0.011). Compared with mass media only, the addition of community participation resulted in better recognition of campaign material and the eHealth platform. CONCLUSIONS: This study was not able to reach a population-level increase of awareness of dementia risk reduction. Two out of the three lifestyle factors that formed the foundation of the campaign were identified more often after the campaign. Those reported having been exposed to the campaign were more aware and more inclined towards behavioural change.

Dementia awareness and risk perception in middle-aged and older individuals: baseline results of the MijnBreincoach survey on the association between lifestyle and brain health.

BACKGROUND: The total number of people with dementia is increasing worldwide, due to our aging society. Without a disease-modifying drug available, risk reduction strategies are to date the only promising way to reduce dementia incidence in the future. Substantial evidence exists that lifestyle factors contribute to the risk of dementia, such as physical exercise, mental activity and (non-)smoking. Still, most people seem unaware of a relationship between lifestyle and brain health. This paper investigates dementia literacy and knowledge of modifiable risk and protective factors of dementia in a Dutch population-based sample. METHODS: An online-survey was carried out among 590 community-dwelling people between 40 and 75 years old in the Province of Limburg, the Netherlands. The total group comprises both of a provincial sample (n = 381) and a sample of three specific districts within the province (n = 209). Dementia awareness and knowledge about 12 risk and protective factors was assessed with items derived from the British Social Attitudes (BSA) survey, supplemented with custom items developed by the research team. RESULTS: The majority of participants (56%) were unaware of a relationship between lifestyle and dementia risk. Most individuals identified low cognitive activity, physical inactivity and unhealthy diet as dementia risk factors. Particular gaps in knowledge existed with regard to major cardiovascular risk factors such as hypertension, hypercholesterolemia and coronary heart disease. Although the level of awareness varied by age and level of education, most people (70%) were eager to learn more about the topic of brain health, and indicated to be interested in using eHealth (54%) to measure or improve brain health. CONCLUSIONS: Most people still are unaware of the relation between lifestyle and brain health, indicating the need for public health campaigns. Increasing awareness in the general population about the presence of modifiable dementia risk and protective factors is a crucial first step prior to implementation of preventative measures. Targeting specific subgroups, such as individuals with low socioeconomic status and low health literacy, is essential for the reach and effect of a prevention campaign. Outcome of this study was the rationale for an awareness campaign in The Netherlands, called "MijnBreincoach" ("MyBraincoach").