World-Wide FINGERS: An International Network of Linked Multidomain Trials

Risk reduction and prevention of dementia in older adults is a growing research area. In the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER randomized controlled trial) a 2-year multidomain intervention -dietary counseling, exercise, cognitive training, vascular and metabolic risk monitoring- improved cognition in older adults from the general population who had increased dementia risk. The intervention was associated also with improvement of other clinical outcomes (e.g., multimorbidity, functional status). The FINGER model is being adapted and tested in different populations and settings through the World-Wide FINGERS, the first global network of multidomain prevention trials, including over thirty countries. The network goal is to identify effective and feasible solution for dementia risk reduction across the spectrum of cognitive decline - from at-risk asymptomatic states to early-symptomatic stages. Through the World-Wide FINGERS-SARS-CoV-2 initiative, the network aims to assess the effects of the COVID-19 pandemic in older adults.

Prevention of functional decline through gamified interventions in hospitalized older adults

This doctoral thesis focuses on the effects of gamified intervention programmes on the functional capacity of hospitalized older adults. Hospitalization is a process that leads to the development of disability in older adults. Hospitalization-associated disability is mainly induced by reduced physical activity and frequent episodes of bed rest during this process of health restoration. Gamified interventions can be a novel and effective strategy to prevent hospitalization-associated functional impairment in elderly patients. This doctoral thesis is based on three studies that have been published in international scientific journals. The first study (Chapter 1) aimed to evaluate the available evidence on the effectiveness of game-based interventions on health parameters (functional capacity, quality of life, etc.) of hospitalized older adults. In the second study (Chapter 2), the main objective was to detail the validation of a pilot multidomain intervention system (physical and cognitive training) based on gamification technologies to improve the functional capacity of hospitalized older adults. In the last study (Chapter 3), the main purpose was to analyse the effects of different modalities of gamified intervention programmes on functional capacity in hospitalized older adults in acute care for the elderly.

Development of the First WHO Guidelines for Risk Reduction of Cognitive Decline and Dementia: Lessons Learned and Future Directions

The first WHO guidelines for risk reduction of cognitive decline and dementia marked an important milestone in the field of dementia prevention. In this paper, we discuss the evidence reviewed as part of the guidelines development and present the main themes emerged from its synthesis, to inform future research and policies on dementia risk reduction. The role of intervention effect-size; the mismatch between observational and intervention-based evidence; the heterogeneity of evidence among intervention trials; the importance of intervention duration; the role of timing of exposure to a certain risk factor and interventions; the relationship between intervention intensity and response; the link between individual risk factors and specific dementia pathologies; and the need for tailored interventions emerged as the main themes. The interaction and clustering of individual risk factors, including genetics, was identified as the overarching theme. The evidence collected indicates that multidomain approaches targeting simultaneously multiple risk factors and tailored at both individual and population level, are likely to be most effective and feasible in dementia risk reduction. The current status of multidomain intervention trials aimed to cognitive impairment/dementia prevention was also briefly reviewed. Primary results were presented focusing on methodological differences and the potential of design harmonization for improving evidence quality. Since multidomain intervention trials address a condition with slow clinical manifestation—like dementia—in a relatively short time frame, the need for surrogate outcomes was also discussed, with a specific focus on the potential utility of dementia risk scores. Finally, we considered how multidomain intervention could be most effectively implemented in a public health context and the implications world-wide for other non-communicable diseases targeting common risk factors, taking into account the limited evidence in low-middle income countries. In conclusion, the evidence from the first WHO guidelines for risk reduction of cognitive decline and dementia indicated that “one size does not fit all,” and multidomain approaches adaptable to different populations and individuals are likely to be the most effective. Harmonization in trial design, the use of appropriate outcome measures, and sustainability in large at-risk populations in the context of other chronic disorders also emerged as key elements.

Multidomain interventions: state-of-the-art and future directions for protocols to implement precision dementia risk reduction. A user manual for Brain Health Services—part 4 of 6

Although prevention of dementia and late-life cognitive decline is a major public health priority, there are currently no generally established prevention strategies or operational models for implementing such strategies into practice. This article is a narrative review of available evidence from multidomain dementia prevention trials targeting several risk factors and disease mechanisms simultaneously, in individuals without dementia at baseline. Based on the findings, we formulate recommendations for implementing precision risk reduction strategies into new services called Brain Health Services. A literature search was conducted using medical databases (MEDLINE via PubMed and SCOPUS) to select relevant studies: non-pharmacological multidomain interventions (i.e., combining two or more intervention domains), target population including individuals without dementia, and primary outcomes including cognitive/functional performance changes and/or incident cognitive impairment or dementia. Further literature searches covered the following topics: sub-group analyses assessing potential modifiers for the intervention effect on cognition in the multidomain prevention trials, dementia risk scores used as surrogate outcomes in multidomain prevention trials, dementia risk scores in relation to brain pathology markers, and cardiovascular risk scores in relation to dementia. Multidomain intervention studies conducted so far appear to have mixed results and substantial variability in target populations, format and intensity of interventions, choice of control conditions, and outcome measures. Most trials were conducted in high-income countries. The differences in design between the larger, longer-term trials that met vs. did not meet their primary outcomes suggest that multidomain intervention effectiveness may be dependent on a precision prevention approach, i.e., successfully identifying the at-risk groups who are most likely to benefit. One such successful trial has already developed an operational model for implementing the intervention into practice. Evidence on the efficacy of risk reduction interventions is promising, but not yet conclusive. More long-term multidomain randomized controlled trials are needed to fill the current evidence gaps, especially concerning low- and middle-income countries and integration of dementia prevention with existing cerebrovascular prevention programs. A precision risk reduction approach may be most effective for dementia prevention. Such an approach could be implemented in Brain Health Services.