"We've greatly overemphasised the effects of normal ageing on the brain." Photo / Mockup Graphics, Unsplash
There is an irony about Sir Muir Gray's campaign against dementia, Dementia Risk Reduction Programme, which launched in the UK on October 1.
The 78-year-old doctor, who founded the NHS's disease screening programmes, has spent his career thinking hard about how the NHS can function better and offer better value, particularly for the elderly.
But among the patient stories which best exemplify his general philosophy about healthcare systems and the old is the very personal story of someone young: his daughter Tat.
Now in her 30s, she developed type 1 diabetes in her teens and then broke her back skiing. It led, says Sir Muir, to a decade of pain, to "10 years of problems not being resolved medically until she decided 'this can't go on' and went to a gym and sorted herself out".
And Gray thinks that message of self-reliance has ramifications far beyond Tat. "Healthcare is what you do for yourself," he says. "It is the most important care, followed by informal care by friends, family and volunteers. Then comes professional care."
It is a DIY attitude, he says, that can help people prevent the diseases of old age ruining their lives, or even getting a grip in the first place. An attitude that focuses on maintaining or recovering strength, stamina, suppleness and sociability whose loss many of us assume is an inevitable consequence of ageing, and so compressing the period of serious debility until as soon as possible before death.
Not that Gray, who spent many years at the top of the NHS, dismisses the brilliance or necessity of doctors and medicine. It's simply that "over the last 40 years, the health service has become a bit focused only on drugs and technology". And as it has done so, he thinks, we patients have become passive about our own health, particularly when it comes to dementia.
But that, he says, is partly because "we're confused – and even doctors are confused – about the relationship between dementia and Alzheimer's". We tend to lump them together. But Alzheimer's, about which we still have so much to learn, is just one cause of the major cognitive problems – not being able to manage finances, or find your way home – we know as dementia. Yet there are several other causes, and they are much more tractable than Alzheimer's. "And the research is now very strong about these other causes and how they can be modified."
The result, he says, is that "it is never too early and never too late to reduce your risk of dementia". Indeed, as a man whose career has been about translating evidence-based medicine into policy-making, he says the time has now come to put these findings – that many causes of dementia are not fated, but can be ducked and delayed – into action.
Hence his upcoming Dementia Risk Reduction Programme, a six-month campaign with two essential aims. The first is to mobilise a network of volunteers to fan out through clubs, churches and societies, from bridge groups to bowls clubs. Essentially, they are to be evangelists, spreading the good news that dementia is far from an inescapable consequence of the passing years. Which is where the second part of his campaign comes in: if you know you can prevent or reduce dementia risk, then how?
There are three strategies. None is hugely surprising. The first is to keep the blood vessels healthy, by stopping smoking, eating well and taking exercise. Think of the brain like the heart, and adopt the same strategy to keep your brain healthy as you would to avoid heart disease.
The second is to protect the brain by cutting down on stress and drugs – "including those prescribed by the medical profession". "There are far too many people in their 70s, 80s, and 90s on eight or more daily drugs that don't work," Gray says. As an aside, he says that the Department of Health admits that a billion pounds a year is spent on drugs that do no good and often do harm: "About a quarter of all admissions of older people are down to drug side effects." Cutting down on booze is predictably important. From one's 50s on, he advises one alcohol-free day per week for every extra decade so that, from 80, four days a week are booze-free. He also prescribes more sleep. "People think older people need less sleep. They need more."
Then there's attitude. "Being positive and socially engaged and having a sense of purpose and being challenged. Challenge is very important. When people retire they often lose challenges in their lives. It's a matter of finding new ones. The best is to help other people, joining a group or getting on a committee of a voluntary organisation. Making a bigger contribution." Not just because such activities are fun, but because new challenges and skills encourage the neuroplasticity that we now know to be vital.
The evidence for all this, he says, is relatively new. "We've greatly overemphasised the effects of normal ageing on the brain," he says, adding that when he was a medical student "we were told that from age 20 the brain cells die off". The reality is that, "while short-term memory slips, which is a 'filing' problem, not dementia, you actually get better at making complex decisions". He points to the late Queen. "It seems her brain was as good as it ever was before she died. Obviously you need a bit of luck, but people need to understand what happens to us as we live longer. It's not due to the ageing process. It's due to a loss of fitness in the body and mind." Age, he says, only truly becomes a contributory factor to cognitive decline "in the late 90s".
If we can get it right, he explains in a Glaswegian accent that has been softened only a little by decades in England, it would mark a dramatic shift in medical priorities since he was a young man. "Fifty years ago, everyone was thinking about children, not old people. But I was interested in them, and thought the importance of activity was neglected." He calls exercise "the miracle cure" with both emotional and cognitive benefits. "Brisk walking is the key. Learning how to do things for yourself. Weights and treadmill."
He certainly seems active himself, publishing books and campaigning well into older age. And he remains influential – earlier this year, he was summoned to Downing Street to see how his dementia programme might fit with a wider government 10-year strategy.
That is a leap from an upbringing amid smoke and poverty in his native Glasgow, where his father, who contracted hepatitis in the war, died when Muir was seven. "We never had a car, and everyone had CLAB – coughing like a bastard," he recalls of those days. But he got a good education and, because his mother's family were farmers, initially trained to be a vet. Then he switched to medicine and, while still in his 20s, became interested in public health. In the mid-1980s, his life was changed after a woman died of cervical cancer under his watch. "I thought 'this is a complete mess, it needs a system'. So I just decided to set up a national cervical screening programme." On the back of that, he set up the breast cancer screening programme, and so it went on.
Such programmes became ways of ensuring value – through prevention – in bureaucratic systems. "I still think healthcare is a huge mess," he says. "But nor can it be viewed as a limitless resource. You can't just assume there will always be another X-ray." As he got older himself, he realised that demography would pose a fundamental challenge to that allocation of resources. "I could see population ageing seen as a tidal wave of need. We had to have a system for living longer, better."
The Dementia Risk Reduction Programme, with six monthly podcasts packed with tips, is his contribution to that goal. The prize is huge, he thinks. "Dementia is one of the big issues, but the good news is we can probably reduce it by about 40 per cent."
1. Stay connected
Spending time with friends and family has been linked to a boost in mental performance.
2. Keep moving
Walking 10,000 steps a day is associated with a lower risk of dementia and other health issues. But experts also found that a faster pace, like a power walk, showed benefits beyond how many steps were recorded.
3. Eat a Mediterranean diet
Research from the University of Edinburgh shows that a Mediterranean diet may help prevent brain shrinkage. So eat plenty of fruits, vegetables, olive oil, beans and cereal grains such as wheat and rice, moderate amounts of fish, dairy and wine, and limited red meat.
4. Quit smoking
Smoking can increase your risk of dementia by between 30 and 50 per cent, says the Alzheimer's Association.
5. Cut back on alcohol
From your 50s on, Sir Muir advises one alcohol-free day per week, with an extra day for every passing decade.
6. Find a sense of purpose
Going to church and volunteering can help reverse memory problems in people with early signs of dementia, research suggests.
7. Get your hearing tested
Losing your hearing is associated with diminished cognitive stimulation, which could raise your dementia risk.
• Constantly forgetting things you were told recently and asking the same questions repeatedly.
• Putting objects in unusual places – like your keys in the bathroom cabinet.
• Frequent problems finding the right word, using substitute words ("that thing you sit on"), jumbling sentence structures, or, if English is your second language, going back to the language you spoke as a child.
• Getting lost in a familiar place or somewhere easy to navigate such as a supermarket.
• Having difficulty making sense of what you see – for example, judging distances on stairs, or mistaking patterns or reflections for other objects.
• Regularly being unable to follow what someone is saying and finding it hard to take part in conversations.
Lewis ran for mayor in Hamilton and Auckland. Earlier, she streaked at All Blacks game.
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