Shifting the needle in cognitive health: urgent action on modifiable risk factors to prevent dementia in Singapore

INTRODUCTION As life expectancy rises, the prevalence of dementia also increases, affecting nearly one in ten Singaporeans aged 60 years and above.[1] This growing challenge is compounded by declining old-age support ratios, creating an urgent imperative to strengthen cognitive health and mitigate the burden of dementia on our healthcare system and society. Recent findings highlight the substantial economic impact of dementia, with the cost of informal caregiving alone reaching SGD 1.28 billion.[2] The recently published 2024 Lancet Commission on dementia prevention, intervention and care reports increasing and ever stronger evidence that tackling key risk factors can reduce the risk of developing dementia.[3] The report states that over 45% of dementia cases can be linked to modifiable risk factors such as high blood pressure, diabetes mellitus, hearing and visual impairment, and lifestyle habits.[3] New evidence suggests that reducing the risk of dementia increases the number of healthy years of life and compresses the duration of ill health for people with dementia.[4] While anti-amyloid therapy has emerged as a disease-modifying treatment for Alzheimer’s disease, the lack of established curative treatments and the high caregiving and socioeconomic burden of dementia heighten the imperative to focus on risk reduction. Interventions to reduce these risk factors are cost-saving, and addressing the risk factors at an early stage, especially in mid-life, accrues benefits to society. In parallel, advancements in diagnostic tools have significantly transformed the early detection of dementia, particularly Alzheimer’s disease. Blood-based and cerebrospinal fluid biomarkers, such as amyloid b and tau proteins, and imaging modalities like amyloid positron emission tomography and functional magnetic resonance imaging, now provide unprecedented insights into the disease’s underlying pathophysiology.[5] By complementing traditional clinical assessments, they support the integration of timely and targeted interventions into clinical protocols, offering the potential to optimise treatment strategies and improve patient outcomes. COGNITIVE HEALTH IN SINGAPORE Singapore has made significant strides in combating metabolic syndrome, diabetes mellitus, heart disease and cancer through effective public health strategies. However, cognitive health has not received the same level of attention, leaving an unmet need in our healthcare system. The latest evidence summarised in the 2024 Lancet Commission presents a pivotal opportunity for Singapore to take proactive measures to address key risk factors for cognitive decline and safeguard cognitive health for the future. In response to the anticipated demographic challenges posed by a growing and ageing population in Singapore, the Ministry of Health outlined a transformative strategy in 2016 known as the Three Beyonds.[6] This approach emphasises three fundamental shifts: moving beyond health care to health, beyond hospital to community and beyond quality to value.[4] The launch of Healthier SG in 2023 highlights the importance of prevention and the role of personal responsibility and activation to meet individuals’ needs effectively in concert with the healthcare system. To support these shifts, a pragmatic, evidence-based tool designed to engage patients in behaviour change and promote cognitive health could be instrumental. One such tool is the recently developed brain care score (BCS),[7] which comprises 12 components targeting key modifiable risk factors for dementia, stroke and late-life depression, and this is in line with the recommendations from the 2024 Lancet Commission on dementia care.[1] Developed in partnership with patients and practitioners, BCS answers the frequently encountered question “How can I take good care of my brain?” with the very best science and in a form that patients welcome. The domains of BCS include physical health markers such as blood pressure, haemoglobin A1c, cholesterol and body mass index; lifestyle factors such as nutrition, alcohol consumption, smoking, physical activity and sleep; and social elements such as stress management, healthy relationships and a sense of purpose in life. These categories represent a holistic and evidence-based approach to brain health, with clear, stratified targets set for various components. Despite the potential and need to significantly reduce the incidence of dementia and stroke, addressing primary prevention of brain disease is not yet part of routine medical care locally and internationally.[8] OPTIMISING COGNITIVE HEALTH THROUGH PRIMARY AND COMMUNITY CARE The expansion and development of primary care is the nexus of the Singapore government’s response to an ageing population, chronic disease burden and increasing healthcare expenditure.[9] The aim of Healthier SG is to empanel residents with general practitioners (GPs) and primary care providers to enhance GPs’ roles in delivering preventive care measures such as health screening, vaccinations and even social prescribing. The BCS could be deployed in the community to objectively assess individuals’ overall lifestyle habits in relation to brain health. Furthermore, because BCS is designed to help individuals set, achieve and maintain their personal goals for maintaining their health, it would serve both to educate the population and motivate them to improve their ‘brain care’, thereby reducing their risk of developing dementia in the future. Of particular appeal, BCS offers measurable lifestyle modifications and targets, especially in the domains of sleep, social relationships and meaning in life, which are less traditionally examined through the lens of health by the general public. A BCS that works well in one context may not perform equally in others due to differences in age, ethnicity, genetic makeup and culture. Derived from the UK Biobank for individuals aged 40–69 years of predominantly European ancestry, BCS requires further evaluation to ensure its applicability in diverse settings like Singapore.[7] Local adaptations, such as tailoring dietary recommendations and addressing region-specific factors influencing social relationships, meaning in life and cognitive health, are essential. These factors, particularly underexplored in Asian contexts, could be better understood through tools like BCS, providing valuable insights to optimise modifiable risk factors. As Singapore develops a robust primary care network to address the shift from health at the individual level to population health,[10] we need tools that holistically identify risk factors, provide guidance on lifestyle change and behavioural modification while motivating individuals to take initiative and become agents in their own health care over the life course. While national strategies for cardiovascular, cancer and even frailty and intrinsic capacity screening exist, no such strategy or tool exists to holistically protect cognitive health at a population level. By integrating such tools into primary care, we can encourage Singaporeans to make small, manageable changes that collectively have a significant impact on their overall health and well-being. This approach is not just for those already facing brain diseases; it shifts the focus from treating brain conditions to actively maintaining brain health, fostering meaningful conversations between patients and healthcare providers about the steps that can be taken to enhance brain care. However, for these interventions to be effective, it is crucial to incorporate insights from behavioural science to understand how best to motivate Singaporeans to improve their modifiable risk factor profiles. Studying behavioural science techniques, such as nudging, habit formation and goal setting, can help design interventions that resonate with the diverse needs and values of our population, ensuring that the proposed changes are both sustainable and impactful. As we consider implementing this approach in Singapore, it is essential to conduct local research to ensure its effectiveness. Key questions include: What features will make tools feasible, acceptable and effective? What will be required to ensure cultural acceptability and feasibility in our multi-ethnic society? In addition, once we establish that improvements in modifiable risk factors lead to a reduction in the risk of dementia and other age-related brain diseases within our population, how can we ensure sustainable implementation within our healthcare system while addressing health disparities across different socioeconomic groups? The BCS is an excellent place to start, but it is just a start. While we anticipate future advancements in medicine that may provide new treatments for age-related brain diseases, we cannot afford to wait. The time to act is now. By embracing optimisation of brain health risk factors and leveraging behavioural science techniques, Singapore can take a decisive step towards integrating routine brain care into our healthcare system, paving the way for a healthier future for all Singaporeans. Financial support and sponsorship Nil. Conflicts of interest Tan BYQ is a member of the SMJ Editorial Board and was thus not involved in the peer review and publication decisions of this article.