Enacting Public Health Policy to Fight Alzheimer’s Disease: An Interview with David Hoffman

We spoke with David Hoffman about a commentary he recently published in the Annals of Bioethics and Clinical Application in which he makes a strong argument for the need to develop clear policies to address the growing public health threat of Alzheimer’s disease.

Hoffman is a Clinical Professor in the Department of Health Policy, Management and Behavior and has served as part of the National Healthy Brain Initiative Leadership Group, the National Alzheimer’s Project Act Advisory Committee at the U.S. Department of Health and Human Services, and on the Task Force on Alzheimer’s Risk Reduction.

First of all, what exactly is Alzheimer’s, and why is it so important?

Alzheimer’s is a disease of the brain known to cause dementia, which is a loss of cognitive function that interferes with daily life. While Alzheimer’s disease is the most common cause of dementia, there are several others as well. This collection of diseases is referred as Alzheimer’s disease and related dementias (ADRD).

ADRD affects a huge number of people each year—in fact, one in nine adults over the age of 65, and one in three adults over age 85 have been diagnosed with dementia. That’s 6.2 million Americans currently, and we expect that number to more than double by the year 2060.

It was once believed that ADRD was an inevitable part of aging and that not much could be done about it, but that view has started to change. Thanks to the landmark Lancet Commission Reports from 2017 and 2020, we now know that there are steps we can take to reduce our individual risk as well as the public health impact of ADRD.

We know that we are going to see significantly more cases of ADRD in the future as the population ages. ADRD will take a significant economic toll because individuals often live for many years after receiving a diagnosis with limited ability to independently care for themselves. If we continue on this course, we can expect to collectively pay 1.17 trillion dollars a year for dementia care by 2050.

Is there anything we should all be doing to prevent ADRD?

Yes, we do have solid evidence that certain health and related behaviors can prevent ADRD, and the good news is that lot of them are common sense, like eating a nutritious diet, getting regular exercise, not smoking tobacco, limiting alcohol use, and so on.

On the population/policy level, we should ensure that every child has access to a quality education beginning in pre-school, because we know that the less education you have the higher your risk for ADRD. We could also potentially reduce the incidence of ADRD by screening for hearing loss regularly, starting in childhood and continuing throughout adulthood, because we have seen a strong association between hearing loss and ADRD. In fact, some researchers believe hearing loss may contribute causally to ADRD. And finally, strong safety regulations to prevent traumatic brain injuries, which are another significant risk factor, could also make an impact.

It's important to make sure that individuals know the risk factors for ADRD, but we also need to make sure that health care providers and policymakers know them as well so that we can make larger structural changes and keep the public informed about how to protect themselves.

It’s interesting that you mention that education is potentially a protective factor, because these days you hear a lot that as you get older you need to “use it or lose it” when it comes to your brain. But you’re saying that even early life education matters?

Yes, the thinking is that early quality education builds resilience and stress reduction, confidence and other strategies that mitigate all the other risk factors. So it’s not necessarily about “use it or lose it,” but about building good coping strategies from an early age. Obviously, there is a social justice element here as well because equal access to high quality education is not the reality in this country.

It’s also easy to understand how racial disparities play a role in this situation. Being a minority heightens your risk of living in poverty and increases your likelihood of being regularly exposed to air pollution, which is another risk factor for ADRD. You are also more likely to live in a food desert, limiting your access to good nutrition. From this perspective, the growing incidence of ADRD may very well be a symptom of growing wealth and social inequality. The bottom line is that chronic high levels of cortisol, which is a chemical triggered in the body by stress, puts people at a higher risk of being diagnosed with ADRD.

Speaking of high stress levels, do you expect the pandemic to have an impact on rates of ADRD diagnosis? There has been a lot of focus lately on the cognitive effects of long COVID and on the toll the pandemic has taken on our mental health.

Yes, I think we will see a “COVID bump” in dementia diagnoses much like we have for the mortality rates for heart disease, diabetes, and so on. I am also convinced that we need new approaches to mental health care, another topic that I have written about recently.  The pandemic has exposed many weaknesses in our current system, which simply cannot handle the influx of new patients.

What’s the biggest challenge we face in successfully implementing public health policy related to preventing ADRD?

It will take time and energy to change the conventional wisdom from ‘there’s nothing we can do’ to a more empowered perspective. The truth is, if we pay attention to these key factors, we can make a real difference.  And many of the things we could be doing to prevent ADRD would prevent any number of other negative health outcomes and improve the health of our society as a whole. In the end, it’s a win-win.