The number of people with dementia in Australia is predicted to reach epidemic proportions by the middle of this century, placing massive burdens on the nation’s health system and economy. A group of researchers want to avert the looming disaster by understanding more about how early intervention can reduce the risks of developing dementia.

Helen Canzano stumbles along the verge by a busy road in outer Toronto. The 90-year-old is dressed too warmly for the mid-summer day. She is spotted by a motorist who later that night sees a TV report about a missing dementia patient, and alerts the police. Helen is found after midnight, disorientated and confused, lying in tall grass in a wood.

This case of a woman lost in the thickets of mental decline was reported in the Toronto Star newspaper on 27 July this year, but it could easily be plucked from its Canadian setting and transplanted to Australia. Similar incidents have been reported in Sydney, Melbourne and Hobart in the last five years. In one case, residents of a suburb were advised by police to check their backyards, where an elderly man with dementia might be cowering in fear.
New South Wales authorities have trialled the use of coded bracelets on so-called ‘wanderers’, those people with a condition like dementia that can leave them bewildered and stumbling through unfamiliar surroundings. Another national system uses mobile phones, which can pinpoint the location of misplaced persons. Such measures provide much-needed comfort to family members and carers, but someone with an eye on the bigger picture might dismiss them as Bandaid solutions.

The problems faced – and posed – by people with dementia are likely to escalate in all advanced industrial nations. Ageing populations mean that the incidence of age-related mental decline will reach unmanageable levels by mid-century. In Australia, the number of people with dementia is currently around 220,000. A 2005 report, commissioned by Alzheimer’s Australia from Access Economics predicted that figure would surge to more than 730,000 by 2050. This growth is all the more alarming when you think about it in dollar figures. Dementia was recently reported to cost Australia $6.6 billion per year in direct and indirect costs. By 2050, this cost is likely to triple. It’s clear that something more than tracking systems will be required if we’re to meet the enormous burdens on our health system, economy and society in general.

The good news is that policy makers are aware of the looming crisis, and are putting measures in place to address it. One of these was the creation of three Dementia Collaborative Research Centres (DCRCs), funded by seven million dollars from the Federal Government in 2006. Each DCRC has a university as its lead node, but also include researchers from ‘nodes’ around the country. One of these ‘virtual’ centres will look into dementia assessment and better care outcomes. Another will consider consumers, carers and social research.

A third centre – DCRC2 – will exclusively focus on prevention, early intervention and risk reduction. The head of this project says that although it won’t be possible to ‘cure’ dementia any time soon, it might be possible to reduce the number of people who’ll succumb to the condition by delaying its onset.

Associate Professor Marc Budge from the ANU Medical School is the Director of DCRC2. He says people sometimes have trouble deciding what to call him, as his work can seem somewhat diffuse to an outsider. He’s a specialist in internal medicine, with interests in “brain imaging, cognitive function over time, how to preserve brain and heart function, and the heart-brain nexus”. He’s sometimes called a geriatrician, given his work on age-related health. He is the head of aged care across ACT Health, and also the President of Alzheimer’s Australia, a national lobby group. He is extremely affable, his smooth voice suitable for use at the bedside of patients or in the boardroom with powerbrokers. But above all else, he is full of energy. This is just as well, given the enormity of the task facing those who would tackle dementia. He came to the subject through earlier work on vascular health and brain function at the University of Oxford. In the mid-1990s, the dementia problem was beginning to ring alarm bells for governments around the world.

“Dementia had been on people’s lips as a priority issue for a few years, but I was really approaching it from the other end: how can we keep people ageing well, not diverging into dementia,” Budge says.

In 2003, Budge returned to Australia to become the Head of Geriatric Medicine at the ANU Medical School. His wish to unite researchers who shared his interest in the early detection and prevention of dementia found the perfect outlet soon afterwards.

“When I started to hear the whispers about [the Federal Government] creating these Dementia Cooperative Research Centres, I thought, ‘If we can help to establish one of those, that would be the right framework’.”

Although it is managed from ANU, DCRC2 pulls together members at a number of nodes: the University of Canberra, the University of Melbourne, Edith Cowan University, the University of Queensland and Alzheimer’s Australia (Victoria). Budge says that ANU provides the management and leadership, but is able to combine with the extensive resources available at its peer institutions to create the overall vision and strategy for the centre’s output.
“It was a significant opportunity for the new Medical School at ANU. We knew it was going to be a stiff competition to win the DCRC. But because of these connections and prior international relationships, we were able to put together a really strong bid.”

One of the stated aims of the DCRCs is to pull together existing research about dementia and convert it into advice and information for policy makers, health practitioners and the public. But in order to raise awareness about the condition, most researchers would agree that it’s important to know exactly what dementia is.

Alzheimer’s Australia defines dementia as “the term used to describe the symptoms of a large group of illnesses which cause a progressive decline in a person’s functioning. It is a broad term used to describe a loss of memory, intellect, rationality, social skills and what would be considered normal emotional reactions”. The lobby group also says that while most dementia sufferers are over 65 years of age, the condition can affect younger people.

Dr Andrew Janke from the Geriatric Medicine Department of the ANU Medical School is also part of the DCRC2 team. He agrees that Alzheimer’s disease is the “poster case” of dementia, but says that there are many other symptoms and factors to consider. Before coming to ANU, Janke was working on brain imaging at McGill University in Montreal, not a million miles away from the Toronto woods in which dementia patient Helen Canzano went missing. Although she was 90 years old, Janke stresses that people at much earlier stages of life need to be alert to the risks of mental decline.

“We talk about neural capacity, which is one of the buzz words in the dementia field, and that differentiation into those who may be at increased risk seems to happen around age 42. At that time you’re starting to diverge down two paths,” Janke says.

Budge joins in: “Given that number 42, you can say that Douglas Adams [writing in The Hitchhikers Guide to the Galaxy] was right,” he says. “42 is the answer. Don’t leave it until you’re 62 or 82. In fact, start at two, and if you can’t start then, then start at 42 to protect and maintain the brain.”

Budge likens dementia to an iceberg. He says there are people who are clearly in the clutches of dementia, because their behaviour and mental activity are noticeably outside the realm of ordinary experience. ‘Wanderers’ might be placed in this category. “But there are probably 10 people for every one of those whose cognitive performance may have decreased, but who may appear to be perfectly normal otherwise to their peers. They’re the people we want to be working with before they get to a stage of obvious dementia.”

After Alzheimer’s, the second most common cause of dementia involves problems around the supply of blood to the brain. Mini-strokes commonly result when blood pressure is too high, or the walls of arteries thicken leading to poor circulation. These small incidents can have large consequences, sometimes leading to irreparable brain damage.

Vascular issues aside, there are a whole host of things that can reduce brain function. Parkinson’s Disease attacks the central nervous system and in its later stages can lead to dementia. Then there are Lewy bodies, small balls of protein that develop inside nerve cells that may manifest as hallucinations and muscle stiffness. Some of the other causes of dementia – such as Fronto Temporal Lobar Degeneration – require exquisite muscle control just to get one’s mouth around them. Despite this diversity of causes, Budge says that the outcomes have much in common.

Initially we notice the loss of brain function reflected in subtle changes in thinking and memory performance, because the brain cells aren’t communicating as well as previously. Eventually, if the dementing process continues it leads to “a loss of brain cells and the shrinkage of brains,” Budge says. “That’s where someone has really got dementia, and it’s difficult for us to reverse that. When the connections are gone, we can’t easily get them back.”

Something much easier than restoring brain function is preventing the grey matter from declining in the first place. This will be the goal of DCRC2 as its members take on four distinct programs looking at different aspects of prevention, early intervention and risk reduction. First, researchers will identify established and emerging risk factors, genetic biological markers, and environment and lifestyle factors. This last aspect is more important than one might suspect.

“Only one to two per cent of cases have a genetic certainty that they’ll get dementia,” Budge says. “The majority of older onset dementias still have increased risk because of their genetic profile, but it’s not sufficient. You need other things happening. Either a predisposition from another point of view, or what happens in life, such as what we might call oxidative stress. There are stressors in the body that are produced that are not good for cells. They are damaging. They insult the DNA so it doesn’t repair as well. If your repairing mechanisms or the ability to respond to those insults is hampered, be they lack of blood flow to the brain or other contributing factors, then you’re left with damaged cells or connections. If you accumulate more and more of this damage without repairing it, it leads to dysfunction.”
Another facet of DCRC2’s work will be the development of better diagnostic tools for early intervention. A major part of this will be the coordination of the Australian Normative and Dementia Imaging (ANDI) Collaborative Network, which will create a central repository for brain imaging. Coordinated by Janke, this project will pull together imaging data from researchers, professionals in the public health system, and public practitioners.
“ANDI is about collecting well-collected brain imaging data and building an average model onto that data.Using this resource, we can give a sensible answer to the person who comes along to the hospital as to whether their brain scan is likely to be ‘normal for age’ or suggest a form of dementia,” Janke says, adding that imaging is currently one of the gold standards for the detection of dementia.

“My eventual goal is to do the same thing for brain imaging for dementia that we do for breast cancer or blood tests or melanoma. A person would go and get a blood test, and the results would be couched in terms of what the averages are for the person’s age, education status, and location etc. I’m not saying we will have an automatic diagnosis. But at least we will have a much better idea of what normal ageing is, which is something that is poorly understood.”
As they develop better understandings of how to detect and intervene in the early stages of dementia, the researchers at DCRC2 intend to get their findings out to medical workers and the community at large. Part of this will include trials of various intervention programs, along similar lines to one facilitated by the Commonwealth Institute in which Budge is involved as a research team leader. Known as the LOOK (Lifestyles Of Our Kids) longitudinal project, this effort will follow 850 primary school children in the ACT over a number of years. In that time, researchers will monitor how the lifestyles of the children relate to their physical health and mental ability.

If the focus of those at DCRC2 can be summed up in a simple way, it’s the idea that tackling dementia isn’t just a matter of peering into the brain – it’s going to involve a more holistic approach that looks at the connection between mental and physical health. Budge emphasises that dementia really needs to be thought of as a socio-political problem as much as a medical one, something that will require a broad response from many sectors. This will be the only way for the nation to avoid what he calls the ‘tsunami of dementia’ later this century.

Andrew on ANDI

Dr Andrew Janke explains the Australia Normative and Dementia Imaging (ANDI) Collaborative Network:

“The idea of ANDI was originally developed during work on a clinical Alzheimer’s MRI (Magnetic Resonance Imaging) project. While scientific discoveries were made, there was very little correlation to the day-to-day problems faced by those at the coal face of dementia care in diagnosis. Some typical questions include: “What type of dementia is this? How long has this patient had it? What would most benefit them right now?”

“Other questions that arise from a patient’s perspective are: “What can I do to ward off dementia? Drink red wine? Play scrabble? Take up gardening?”

“We know that dementia will reach epidemic proportions within the next 30 years. So prevention and early identification of progressive problems of the brain will be critical areas requiring development in order for our society to manage this burgeoning problem.

“A number of existing studies have been performed within Australia that are aimed towards a certain type of dementia.

“The best approach to studying the problem of dementia in our community as a whole would be to first aggregate as much previous data as possible and then add routine clinical imaging into the mix. This will allow us to characterise the development of the various dementias as a whole.

“In order to gain insight into these questions, studies involving very large numbers of people are needed so that we can draw inferences about the effects of things like education, income status and accommodation on the progression of dementia. We know, for example, that caring for someone with dementia in your own home increases your own risk of depression which can in turn lead to dementia. To combat this, should the government fund more nursing home places or respite care?

“Subsequently the need for a project such as ANDI is paramount given that it will provide the database of imaging and psychometric data that will allow us to answer such questions.”

More: www.andinetwork.com.au

Mind your mind
Alzheimer’s Australia has developed seven steps that can help people reduce their risk of developing dementia.

Mind your brain
Keeping the brain active is thought to build reserves of brain cells and enhance their connections, helping keep you mentally sharp. Do mind games, take a language course, keep up hobbies, do activities around the house.

Mind your body
Physical exercise encourages blood flow to the brain. People who exercise regularly are less likely to develop heart disease, stroke and diabetes. These conditions are associated with an increased risk of developing dementia. Exercise aerobically at least 20-30 minutes three times a week. You can walk, dance, jog, cycle, swim, garden ... anything that gets the body moving and the heart pumping.

Mind your diet
A good balanced diet promotes brain health. Reduce saturated fats. Eat protective foods, including ‘good’ cholesterol like monounsaturated and polyunsaturated fats, olive oil, avocados, olives, nuts, seeds and fish. Also seek out antioxidant-rich foods such as prunes, raisins, and blueberries.

Mind your health checks
Having check-ups and following the medical advice of your doctor is important for general health and brain health. Mind your body weight and avoid obesity. Mind your blood pressure and seek treatment if it is too high. Mind your cholesterol and keep the ‘bad’ cholesterol low. Mind your blood sugar levels and, if you have diabetes, manage it well.
Mind your social life

Being socially involved and participating in leisure and other activities with people helps maintain a healthy brain. Keep in contact with family and friends. Participate in clubs, social, cultural or other groups. Keep on working, or become a volunteer. Enjoy conversation with your neighbours, shop assistants, on the radio.

Mind your head
Protect your head to reduce your risk of dementia. Avoid head injury. Always use a seatbelt. Take special care when you are a pedestrian. Use protective headgear when riding, skating and playing sport.

Mind your habits
Avoid ‘bad habits’, such as smoking and drinking too much alcohol. For general health, it is helpful to reduce stress and get a good sleep.

Adapted from Alzheimer’s Australia ‘Mind Your Mind’ initiative.

More: www.alzheimers.org.au

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ANU Reporter 
Spring 2007