Protecting the Mind
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Singapore is one of Asia’s most rapidly ageing societies, emblematic of the advancements made in our healthcare system and the improvements in our standard of living. The average life expectancy of Singaporeans has risen to second highest globally, behind only Japan. Most Singaporeans today can expect to celebrate their 84th birthday. Correspondingly, the percentage of Singaporeans over the age of 65 has increased considerably in a comparatively short span of time, from 9.9% in 2012 to 16% in 2022.
Growing old often heralds new health challenges and concerns, and dementia is one of the most common diseases afflicting the elderly population in Singapore. About one in ten Singaporeans aged 60 and above suffer from dementia. This equates to approximately 82,000 Singaporeans with dementia in 2018. This number
is estimated to double by 2030.
Predictably, dementia stands out as one of the most common fears reported by patients at the geriatric clinic. Although growing older does not equate to living a less meaningful life, the immutable truth remains that age is a primary risk factor for dementia.
DEMENTIA
Contrary to the prevailing belief that dementia refers to a singular disease entity, it is actually a clinical syndrome that describes a broad range of neurodegenerative disorders. A key feature of dementia is a marked decline in cognitive function from premorbid levels. This decline is not part of normal ageing, and it adversely affects a patient’s ability to perform activities of daily living (e.g., personal care, housework, managing finances, navigating in the community, etc.). Subjective cognitive difficulties can manifest in forgetfulness, poor problem-solving or communication difficulties. Mood issues, personality changes and problem behaviours may also emerge concurrently.
Figure 1: Population attributable fraction of potentially modifiable risk factors for dementia (from Livingston, G., Huntley, J., Sommerlad, A., Ames, D., Ballard, C., Banerjee, S., Brayne, C., Burns, A., Cohen-Mansfield, J., Cooper, C., Costafreda, S. G., Dias, A., Fox, N., Gitlin, L. N., Howard, R., Kales, H. C., Kivimäki, M., Larson, E. B., Ogunniyi, A., & Orgeta, V. (2020). Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. The Lancet, 396(10248), 413–446.)
PREVENTION
Despite the ongoing hunt to find a panacea for dementia, there is currently no scientifically-proven treatment and no known means of completely eliminating the risk of dementia.
However, contemporary research has identified several prominent modifiable risk factors for dementia (see Figure 1). The highest loading factors found for onset of dementia in later life include smoking, depression, social isolation and physical inactivity. Therefore, it is evident that older adults can play an active role in reducing their overall risk of dementia or delaying the onset of dementia by observing positive lifestyle practices. Let us now take a look at some of the main modifiable risk factors.
SMOKING
Evidence suggests that smokers have a higher risk of developing dementia as compared to non-smokers. Even second-hand exposure to smoking is associated with the deterioration of memory faculties. Conversely, smoking cessation for a prolonged period, even at older ages, can reduce dementia risk to levels comparable to that of individuals who have never smoked.
Although there is a staggering amount of evidence affirming that smoking results in poorer health outcomes, we know that quitting any form of addiction will undeniably be an arduous struggle. For individuals who experience difficulty quitting smoking independently, calling helplines or visiting smoking cessation clinics might be beneficial. For non-smokers, you should be mindful of your surroundings and consciously avoid second-hand smoke exposure.
DEPRESSION
Although the prevalence of mood disorders tends to decline with age, late-onset depression is one of the most common psychiatric disorders in older adults aged 55 and above. Studies suggest that late-life depression increases the risk of developing cognitive impairment and elevates the risk of getting dementia. The more severe the depressive symptoms, the faster the rate of cognitive decline and the more impaired cognitive function becomes. More alarmingly, depression in early adulthood
is associated with a higher likelihood of developing dementia later in life.
It is crucial for us to safeguard our mental health. Early intervention is essential to improving our mental health prognosis and ensuring better health outcomes. Should you be experiencing significant psychological issues that you cannot cope with alone, you should strongly consider seeking additional support from professionals, such as psychiatrists, psychologists or counsellors. A wide range of mental health resources can also be found online, including the HealthHub
and National Council of Social Service websites.
SOCIAL ISOLATION
According to a study conducted by Duke-NUS’s Centre for Ageing Research and Education in 2016 and 2017, around a third of Singaporeans perceived themselves to be lonely, and this proportion only increased with age.
The advent of the COVID-19 pandemic in 2020 likely exacerbated the situation, as older adults had to stay at home due to pandemic restrictions and their well-founded fears of contracting the disease. Anecdotally, a noticeable number of older adults seen at the hospitals in the past few years have expressed feelings of boredom or loneliness during the pandemic. Individuals who are single or no longer married; living alone; and have a limited social network or a lack of social engagement with others are at higher risk of experiencing social isolation. This is concerning as social isolation has been proven to have strong links with cognitive decline and dementia. Notably, the subjective experience of feeling lonely, rather than the objective situation of being alone, was found to be associated with an increased risk of dementia in later life.
Social interaction with others is a basic necessity. We find meaning and joy in the bonds we form with others and in our shared experiences. Therefore, it is
imperative to take steps to alleviate social isolation in older adults and facilitate greater social integration with their community. Social service agencies’ assistance may be helpful as they provide services, such as checking in on older adults via video and phone calls, delivering meals, and teaching them how to stay connected to online support services. If seniors fail to respond to check-ins, some social service agencies will send staff to their homes to check on their well-being. Older adults can try participating in activities or workshops at community centres or make valuable contributions to society by volunteering in programmes like the Community Befriending Programme.
PHYSICAL ACTIVITY
A local study published in 2021 found that 16.6% of a sample population did not meet minimal physical activity requirements.
The Health Promotion Board defined this as having 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity physical activity a week.
According to the study, older adults have a lower probability of participating in sufficient physical activity than their younger counterparts. This is likely due to increased frailty and mobility issues. However, longitudinal studies have shown that exercise can reduce the risk of dementia, and regular physical exercise can help preserve the cognitive function of healthy elderly adults.
Guidelines from the World Health Organization advise that physical exercise, particularly aerobic exercises like swimming or walking, has a small but beneficial effect on mild cognitive impairment. Physical activity also has a nontrivial preventative effect against dementia as it contributes secondarily towards mitigating other significant modifiable dementia risk factors, such as depression (exercise is an effective stress reliever and mood enhancer), social isolation, diabetes, obesity and hypertension.
A comprehensive medical check-up is recommended for sedentary older adults or individuals who have not been exercising regularly before beginning any activity. This will allow healthcare professionals to rule out any medical or chronic conditions that might preclude them from doing specific exercises.
Exercising regularly does not have to be a major commitment, even daily brisk walks or light exercise at home can reduce dementia risk. Other activities suitable for seniors include Tai Chi, Pilates, Zumba, water aerobics and jogging.
CONCLUSION
Dementia can have a profound and harmful impact on people and their loved ones. We should be cognisant of the modifiable risk factors and recognise that we can take preventative steps to reduce our overall dementia risk.
However, we should also keep in mind that dementia does not mean a patient is incapable of living a regular life or will be unable to enjoy the things he/she used to love. A timely diagnosis will empower a patient to plan for his/her future and maximise his/her quality of life. While there is no cure, pharmacotherapy, compensatory strategies and maintaining a healthy lifestyle can still help individuals live meaningful lives beyond their dementia diagnosis.
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