The legacy of the 2013 G8 Dementia Summit: successes, challenges, and potential ways forward

Dementia is a public health and socioeconomic concern that is widely predicted to worsen as the proportion of older adults making up our global population increases.1Livingston G Huntley J Sommerlad A et al.Dementia prevention, intervention, and care: 2020 report of the Lancet Commission.Lancet. 2020; 396: 413-446Summary Full Text Full Text PDF PubMed Scopus (516) Google Scholar By 2050, 152 million people worldwide are expected to experience dementia, along with its associated impact. In an ambitious act to galvanise a global response, the 2013 G8 Dementia Summit was convened with a primary aim to identify a cure or disease-modifying therapy for dementia by 2025.2G8 Dementia Summit declaration.https://www.gov.uk/government/publications/g8-dementia-summit-agreements/g8-dementia-summit-declarationDate: Dec 11, 2013Date accessed: January 4, 2021Google Scholar New evidence has since deepened our understanding of the potential for disease-modifying therapies, making this target even more unrealistic. In parallel, rapidly accumulating evidence has emphasised the importance of broader societal policies for dementia prevention across the lifecourse.3Rakesh G Szabo ST Alexopoulos GS Zannas AS Strategies for dementia prevention: latest evidence and implications.Ther Adv Chronic Dis. 2017; 8: 121-136Crossref PubMed Scopus (63) Google Scholar Here, we review the goals, progress, and challenges of the Summit activities, and propose potential ways forward to align policy with the public health evidence for dementia prevention. At the Summit, health ministers agreed on a list of commitments (panel), as well as the development of a coordinated international action plan for dementia research, which would be delivered by the newly formed World Dementia Council (WDC), formed by representatives appointed from academia, industry, and civil society.PanelList of G8 Dementia Summit commitments1Call for greater innovation to improve the quality of life for people with dementia and their carers while reducing emotional and financial burden.2Identify a cure or a disease-modifying therapy for dementia by 2025 and increase collectively and substantially the amount of funding for dementia research to reach that goal.3Report biennially on expenditure on publicly funded national dementia research and related research infrastructure, and increase the number of people in dementia-related research studies.4Work together, share information about the research we fund, and identify strategic priority areas, including sharing initiatives for big data, collaboration, and cooperation.5Develop a coordinated international research action plan that accounts for the current state of the science, identifies gaps and opportunities, and lays out a plan for working together to address them.6Encourage open access, where possible, to all publicly funded dementia research and make the research data and results available for further research as quickly as possible, while protecting the privacy of individuals and respecting the political and legal frameworks of the countries in which the research is done.7Take stock of our current national incentive structures for research, working in partnership with the OECD, and consider what changes could be made to promote and accelerate discovery and research and its transformation into innovative and efficient care and services.8Hold a series of high-level fora throughout 2014, in partnership with the OECD, WHO, the European Commission, the EU Joint Programme on Neurodegenerative Disease, and civil society, to develop cross-sector partnerships and innovation, focused on social impact investment (UK led), new care and prevention models (Japan led), and academia–industry partnerships (co-led by Canada and France).9Call upon WHO and the OECD to identify dementia as an increasing threat to global health and support countries to strengthen health and social care systems to improve care and services for people with dementia.10Call upon the UN Independent Expert on the enjoyment of all human rights by older people to integrate the perspective of older people affected by dementia into their work.11Call upon all sectors to treat people affected by dementia with dignity and respect, and to enhance their contribution to dementia prevention, care, and treatment where they can.12Call upon civil society to continue and to enhance global efforts to reduce stigma, exclusion, and fear.13Meet again in the USA in February, 2015, with other global experts, including WHO and the OECD, to review the progress that has been made on our research agenda.OECD=Organisation for Economic Co-operation and Development. 1Call for greater innovation to improve the quality of life for people with dementia and their carers while reducing emotional and financial burden.2Identify a cure or a disease-modifying therapy for dementia by 2025 and increase collectively and substantially the amount of funding for dementia research to reach that goal.3Report biennially on expenditure on publicly funded national dementia research and related research infrastructure, and increase the number of people in dementia-related research studies.4Work together, share information about the research we fund, and identify strategic priority areas, including sharing initiatives for big data, collaboration, and cooperation.5Develop a coordinated international research action plan that accounts for the current state of the science, identifies gaps and opportunities, and lays out a plan for working together to address them.6Encourage open access, where possible, to all publicly funded dementia research and make the research data and results available for further research as quickly as possible, while protecting the privacy of individuals and respecting the political and legal frameworks of the countries in which the research is done.7Take stock of our current national incentive structures for research, working in partnership with the OECD, and consider what changes could be made to promote and accelerate discovery and research and its transformation into innovative and efficient care and services.8Hold a series of high-level fora throughout 2014, in partnership with the OECD, WHO, the European Commission, the EU Joint Programme on Neurodegenerative Disease, and civil society, to develop cross-sector partnerships and innovation, focused on social impact investment (UK led), new care and prevention models (Japan led), and academia–industry partnerships (co-led by Canada and France).9Call upon WHO and the OECD to identify dementia as an increasing threat to global health and support countries to strengthen health and social care systems to improve care and services for people with dementia.10Call upon the UN Independent Expert on the enjoyment of all human rights by older people to integrate the perspective of older people affected by dementia into their work.11Call upon all sectors to treat people affected by dementia with dignity and respect, and to enhance their contribution to dementia prevention, care, and treatment where they can.12Call upon civil society to continue and to enhance global efforts to reduce stigma, exclusion, and fear.13Meet again in the USA in February, 2015, with other global experts, including WHO and the OECD, to review the progress that has been made on our research agenda. OECD=Organisation for Economic Co-operation and Development. There are several key limitations to the G8 commitments made in 2013 that have reduced their impact and the likelihood of meeting their aspirations, despite the creation of the WDC. It is worth reflecting on why this might have been the case. Although the commitments made at the G8 Dementia Summit were important, the majority were not specific, measurable, or time bound, and did not have any reporting or accountability mechanisms in place. The WDC action plan was never technically tied back to the individual commitments made by the G8 countries, nor to a realistic analysis of the evidence base that was often assumed rather than proven. Instead, the WDC places emphasis on expert opinion over evidence, and often selects these experts from a few relatively narrow sectors of the field, with over-representation of the private sector. As a collaboration between international organisations, accountability and reporting on the WDC's outputs has no clear lines of sight and cannot be traced back to the responsibility of a single organisation. This makes robust evaluation difficult, if not impossible. Finally, as evidence amasses and research priorities shift, there is no mechanism for modification of the original Summit commitments and goals. The G8 Summit's commitment to identifying a cure or disease-modifying therapy for dementia by 2025 represented a lofty and unrealistic goal—except, perhaps, for very rare genetically inherited early-onset dementias. Evidence was compelling then, and even more so now, that single-protein targets are insufficient to prevent cognitive decline, much less to show clinically meaningful long-term benefit to individuals’ quality of life. Research findings continue to challenge the dominant hypothesis that most dementia is caused by Alzheimer's disease and reflects the overaccumulation of amyloid plaques, and instead suggest that it is probably determined through multiple, interacting pathways, particularly in the oldest old (≥95 years).4Savva GM Wharton SB Ince PG Forster G Matthews FE Brayne C Age, neuropathology, and dementia.N Engl J Med. 2009; 360: 2302-2309Crossref PubMed Scopus (643) Google Scholar Since the Summit, the dementia research field, which has been strongly driven by a relatively narrow research community, has focused on Alzheimer's disease; this has then been over-represented in almost all areas of dementia research and policy development, including within the WDC. The WDC has perhaps struggled to represent a coherent and grounded approach. Experts claim in the same breath that Alzheimer's disease is likely to be the result of a complex combination of mechanisms, but that pharmacologically narrow target-driven cures for the disease are still promising. Evidence from community-based autopsy series have clearly shown that many people without dementia have many of these pathological brain changes as well.5Wallace LMK Theou O Godin J Andrew MK Bennett DA Rockwood K Investigation of frailty as a moderator of the relationship between neuropathology and dementia in Alzheimer's disease: a cross-sectional analysis of data from the Rush Memory and Aging Project.Lancet Neurol. 2019; 18: 10Summary Full Text Full Text PDF PubMed Scopus (100) Google Scholar It is quite possible that neuropathological features and burden will come to be thought of as another set of risk factors, rather than a disease-defining feature.1Livingston G Huntley J Sommerlad A et al.Dementia prevention, intervention, and care: 2020 report of the Lancet Commission.Lancet. 2020; 396: 413-446Summary Full Text Full Text PDF PubMed Scopus (516) Google Scholar The fact that many researchers in the field continue to perseverate on the amyloid hypothesis and single-protein drug targets is perhaps a reflection of political processes and environments; those who have lobbied for funds and created major programmes of work (including future-looking capacity building focused on the same approaches) are also deciding on the strategic investments that are needed as a response to their own predicted global tsunami of dementia. This analysis is supported by the legacy meeting in 2018 hosted by Alzheimer's Research UK, where participants discussed and set recommendations for dementia research, with goals entirely focused on drug development. A further example is the enduring and powerful hold of interventions to improve early detection through measurement of biomarkers in mid-life, with massive investment and multiple initiatives. This is problematic for many reasons, the most critical of which is that there are no appropriate treatment options for those with an early diagnosis and we cannot yet know the safety profile of long-term consumption of such medications, which are themselves likely to be promoted in combinations. Despite strong evidence that public health policy can reduce dementia incidence, no commitments from the G8 Summit specifically focused on population approaches to primary risk reduction. Reductions in age-specific incidence of dementia in high-income countries6WHORisk reduction of cognitive decline and dementia: WHO guidelines. World Health Organization, Geneva2019Google Scholar, 7Norton S Matthews FE Barnes DE Yaffe K Brayne C Potential for primary prevention of Alzheimer's disease: an analysis of population-based data.Lancet Neurol. 2014; 13: 788-794Summary Full Text Full Text PDF PubMed Scopus (1184) Google Scholar are probably due to widespread adoption of public health measures during the 20th century that improved population health as a whole.8Matthews FE Stephan BCM Robinson L et al.A two decade dementia incidence comparison from the Cognitive Function and Ageing Studies I and II.Nat Commun. 2016; 711398Crossref PubMed Scopus (209) Google Scholar Public health approaches to address common age-related, but modifiable, disease risk factors such as smoking, obesity, and hypertension are likely to reduce incidence of not only dementia, but other causes of later-life morbidity and mortality such as cardiovascular disease, cancer, and diabetes. What many of these risk factors have in common is that they are highly linked to socioeconomic factors such as poverty and marginalisation. Importantly, there is also ample public health evidence that individually targeted interventions, which require conscious behavioural change, exacerbate these inequalities and are unlikely to produce maximal benefit or be cost-effective.9Marteau T Changing minds about changing behaviour.Lancet. 2018; 391: 116-117Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar Given the increasing burden of dementia and cardiometabolic disease in low-income and middle-income countries, broad scalable solutions are needed more than ever.10WHOGlobal action plan on the public health response to dementia: 2017–2025. World Health Organization, Geneva2017Google Scholar Therefore, further research on the ways in which we can reduce risks across populations as well as enhance protective factors such as cognitive resilience are necessary; however, investment remains pitiful when placed against the heroic investments into pharmacological approaches. One way to tackle the potentially modifiable risk factors identified by the latest Lancet Dementia Commission, theoretically reducing dementia risk by up to 40%,1Livingston G Huntley J Sommerlad A et al.Dementia prevention, intervention, and care: 2020 report of the Lancet Commission.Lancet. 2020; 396: 413-446Summary Full Text Full Text PDF PubMed Scopus (516) Google Scholar is to create inclusive spaces that promote health and wellbeing across the lifecourse. Although there has been increasing emphasis on so-called age-friendly and healthy cities, which create environments that encourage safety, wellness, and active participation of citizens across the lifecourse, with small-scale research suggesting some success, there has been little large-scale investment or adoption. Politically and financially supported initiatives, which include policies on housing, transportation, outdoor space, health services, and civic participation, to facilitate physical activity, education, social interaction, and proper nutrition have been shown to reduce risk for almost all age-related diseases. A crucial benefit of this approach is that these societal-level interventions are likely to reduce inequality by creating the most impact in the proportion of the population who stand to gain the most. The global COVID-19 pandemic will pose important challenges for creating structural changes that promote dementia prevention. In the USA, deaths attributed to dementia increased during the pandemic and exposed crucial gaps in our systems for caring for and including people with dementia in our response efforts. These gaps have been even wider for those already at disadvantage in society. The pandemic has also led us to consider how we value young lives and personal freedom against the value of older people and their health and safety. Any efforts that aim to produce population-level risk reduction will need to take into consideration the barriers imposed by pandemic precautions, and legislation for the precautions enforced should make specific recommendations in light of the harm–benefit calculation for older adults living with dementia, their families, and care structure. It is also, however, a global opportunity. In conclusion, the G8 Summit marked an important advance in the dementia field in terms of recognition and momentum. Since then, we have made many advances in understanding dementia risk reduction, prevention, intervention, and care, which should be reflected by updated commitments and action plans based on the latest evidence. In particular, we urge an evidence-based examination of the population benefit from investment in various approaches, with an emphasis on addressing inequalities, healthy ageing, and sustainability. We hope this will shift the current emphasis towards a middle ground between biomedical and societal or public health responses to maximise population benefit. Scaling up strategies that are cost-effective, inclusive, and multidomain is complex, but is the only sustainable way to improve quality of life as the world ages. Further reading is provided in the appendix. We report no competing interests. Download .pdf (.15 MB) Help with pdf files Supplementary appendix

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.