Results and discussion

Prevention of dementia at a structural level

What does dementia prevention look like in the Nordic countries? This chapter explores the unique approaches taken by each country in the region to tackle this pressing issue and outlines the key components of their dementia prevention policies.

Norway

There is no specific dementia prevention strategy in Norway, as the Norwegian government builds on the same principles as those that underpin public health policy.

“As there is no cure or single measure that works against dementia, prevention of dementia must be based on a holistic and broad approach, including individual and population-based prevention.”

Interviewee, Norway 2023-2024

The approach to preventing dementia in Norway rests on WHO guidance, with the WHO action plan on the public health response to dementia (WHO, 2019) as the key document. Demensplanen 2025 by the Norwegian Ministry of Health and Care Services (Helse- og omsorgsdepartementet, 2020) is a central policy document on dementia care, which also includes the prevention of dementia. The plan focuses on the need of increased research and knowledge about prevention and has a broad approach to prevention.

“In the prevention of dementia, the government will build on the same principles that underlie public health policy, by facilitating good health for everyone with more good years of life and quality of life, reducing adverse environmental and lifestyle factors and reducing social inequality in health.”

Helse- og omsorgsdepartementet, 2020

Because dementia and other NCDs have shared risk factors, dementia prevention is described as a part of the NCD measures in Norway, i.e., the more general public health measures (Norwegian Institute of Public Health, 2010).

The public health act is a Norwegian law that gives municipalities, county councils, and state authorities responsibility for promoting public health (Lovdata, 2012). This also reflects the Norwegian government’s strategy document named Folkhelsemeldinga on good public health as the fundament of health and care policy (Den norske regjeringen, 2023). As the government strategy for reducing social health differences, it presents the government’s effort to promote better public health and a good quality of life in the population. It also reflects a holistic approach to prevention.

Norway’s has previously had a national NCD strategy, and Folkehelsemeldingen recommends that it is to be renewed. A new tobacco strategy is part of the Folkehelsemeldingen and includes a request to ban the online sale of tobacco products, as well as no flavouring in e-cigarettes. In addition, the Norwegian government has a national plan for preventive health and care services in the Nasjonal plan for helse og samhandling (Den norske regjeringen, 2024), an action plan for physical activity (Den norske regjeringen, 2020), a national dietary action plan (Norwegian Directorate of Health, 2023), and a national alcohol strategy 2021–2025 (Den norske regjeringen, 2021). Smoking, alcohol, an unhealthy diet and low physical exercise are all risk factors for dementia. Norway has a quality reform by the Ministry of health and care services called Leve hele livet, and aims to help older adults to cope with life and have a safe and active old age (Den norske regjeringen, 2018).

Iceland

The Iceland health services policy is valid until 2030 (Government of Iceland, Ministry of Health, 2019). According to this document, the strategy for dementia prevention is an overall prevention of NCD diseases in older adults, following the WHO recommendations for primary prevention (WHO, 2019). In 2020 Iceland joined forces with WHO together with a number of other countries to support an integrated approach to brain health (WHO, 2020). The WHO brain health unit works to strengthen policies, service delivery in the health information system, and so on in the area of brain health with a focus on promotion, prevention, treatment, care, and rehabilitation (Brain Health Unit WHO, 2024). The collaboration with WHO seemed to inspire the Icelandic work to a more systematic direction promoting good brain health among the general population.

Iceland also has a specific national action plan for dementia based on a white paper. This plan was adopted by the parliament in April 2020, and will apply until 2025 (Goverment of Iceland, 2020).

The national action plan for dementia includes six main target areas (Ísland.is, 2021):

Self-determination, patient involvement, and legal framework.
Prevention.
Timely diagnosis and follow-up after diagnosis.
Activity, self-help, and support.
Appropriate service in relation to the stage of dementia.
Scope, research, knowledge, and skills.

The chapter about prevention describes two actions: one deals with social isolation as a risk factor for dementia, the other with health promotion to prevent dementia. It’s effective to acknowledge the synergies in promoting good health for the heart and the brain at the same time.

The Minister of Health and the Minister of Social Affairs and Labour Market appointed a working group in June 2022 to do an overall audit of services for older adults and to lead the implementation of the action plan on health promotion for them (Ísland.is, 2021). A specific initiative was started, Good to Grow Old, which aims to improve healthy ageing through comprehensive health promotion and flexible services. The service has already improved access to advice and information about services for older people. The comprehensive health promotion includes information on and access to health promotion measures, whether physical, social, or psychological.

“All aboard. The key to success in dementia prevention is that everyone is rowing in the same direction; there is the state, there are municipalities, there are other public sectors and various NGOs.”

Interviewee, Iceland 2023-2024

Denmark

A central report from 2022 in Denmark describes the significance for the society of 15 diseases, dementia included (Mairey et al., 2022). These have been selected because they have shown to have a significant impact on the state of health globally (Institute for Health Metrics and Evaluation, 2019). Factors such as quit smoking, reduce alcohol intake, and regular exercise may help to reduce the risk of several chronic diseases, and represent a general approach in the prevention work with a focus on healthy ageing. In connection with work on promoting healthy ageing, the Danish Health Authority published a report as input for the political action plan. This report contains a series of recommendations (Sundhedsstyrelsen, 2022c), all aimed at supporting good ageing – ensuring that as many older adults as possible experience healthy ageing with vitality and quality of life. As dementia was addressed in the dementia action plan (Sundheds- og ældreministeriet, 2016), it is not included as a separate issue here, but a health promotive approach is clear. The report by Danish Health Authority explicitly highlights physical exercise and cardiovascular health, as well as lifelong physical activity, education, social activities, and cognitive stimulation. These risk factors are all in line with the risk factors for dementia highlighted in Livingstone et al. (2020). Additionally, alcohol is mentioned as a specific risk factor. Another Danish report from Danish Health Authority describes the burden of disease for nine selected risk factors: severe obesity, smoking, alcohol consumption, low physical activity, unhealthy diet, sleep problems, loneliness, low score on the mental health scale and air pollution (Sundhedsstyrelsen, 2022b, 2023). The prevention packages are intended as a knowledge-based tool for the municipalities in Denmark working with general prevention and public health.

“There is a political focus on healthy ageing in general, and how to have a healthier and better older life, with less need for support and assistance.”

Interviewee from Denmark 2023-2024

The national dementia action plan in Denmark has five focus areas, but prevention is not one of them (Sundheds- og ældreministeriet, 2016). A significant reason is that the working groups behind the dementia action plan at the time found limited evidence for specific measures when the action plan was drawn up beyond public health recommendations.

Denmark has a specific national Research strategy on dementia for the period 2018–2025 which is exceptional in a Nordic context. The Danish Health Authority (2018) defined recommendations for research to meet the human and societal challenges of dementia. The work on the research strategy was conducted by an expert group including representatives from the Danish Health Authority, Danish Dementia Research Centre, and the Danish Agency of Higher Education and Science. Based on research needs and existing international research strategies, four strategic themes of dementia research were identified. Prevention, treatment, and psychosocial intervention is one of the four themes now part of the Danish research strategy in the field of dementia (Danish Health Authority, 2018; Institute for Health Metrics and Evaluation, 2019). The research strategy draws from the idea that effective prevention of dementia builds on greater understanding of the causes and mechanisms of the disease, e.g., in the form of multi-domain interventions which could include lifestyle changes, treatment of disease, and the strengthening of physical and cognitive resources.

Sweden

The Ministry of Social Affairs and Health has the overall responsibility for the broad public health policy in Sweden. The Public Health Agency has issued a fundamental policy document a public health policy framework based on eight target areas for good and equal health (Folkhälsomyndigheten, n.d.). Target area number six about lifestyle habits, contains the following focus areas:

Limited availability to products harmful to health.
Increased accessibility to health-promoting products, environments, and activities.
Strengthen health promotion and preventive work on lifestyle risk factors in the welfare institutions

In 2011, the Swedish National Board of Health and Welfare published national guidelines for disease-preventing methods, a national guideline of ways of counteracting unhealthy lifestyle risk factors such as alcohol use, tobacco use, unhealthy eating habits, and insufficient physical activity. In 2018 a renewed version was published with the updated title Nationella riktlinjer för prevention och behandling vid ohälsosamma levnadsvanor: Stöd för styrning och ledning (Socialstyrelsen, 2018). These national guidelines for the prevention and treatment of unhealthy lifestyles are currently being updated and to be published in 2025.

The National Board of Health and Welfare has created a deck of trainings and support materials to help healthcare personnel in lifestyle counselling with patients on such questions as eating habits, tobacco, alcohol, and physical activity (Socialstyrelsen, 2019). These can be discussed with patients whenever they visit a healthcare centre or hospital. The guidelines do not, however, mention the prevention of dementia. Since 2021, primary health care in Sweden has been given the responsibility to lead health promotion efforts for its residents (Socialstyrelsen, 2021).

It is anticipated that the forthcoming Social Services Act, scheduled for implementation in summer 2025, will place greater emphasis on health promotion and prevention. The Social Service Act-proposal referred to the Swedish Council on Legislation for consideration in July 2024, emphasises for instance good living conditions for all and counteracting alcohol addiction. The proposal also highlights the needs of supporting health and functional capacity in older adults. Healthy food and physical activity are mentioned as important health promotive measures for this purpose (Socialdepartementet, 2024).

”It is possible that the new legislation will affect municipalities’ work on dementia prevention in the future, although the precise manner in which this will occur remains unclear.”

Interviewee from Sweden, 2023-2024

The government of Sweden decided on the national dementia strategy in May 2018 (Sveriges regering, 2018). In 2020, the National Board of Health and Welfare published the target levels of indicators clarifying the categorisation of dementia diseases associated with the term public diseases. In 2023, the Swedish government commissioned the National Board of Health and Welfare to produce a knowledge report for a renewed national dementia strategy. The board has been gathering insights from relevant experts and stakeholders such as the Swedish Dementia Centre, the National Competence Centre for Relatives, the Swedish Association of Local Authorities and Regions, and other interest groups. In February 2024, the board published the knowledge report for the renewed dementia strategy (Socialstyrelsen, 2024). The assignment from the Swedish government included the perspective on health promotion and prevention for the renewal of the Dementia strategy. The knowledge report highlights early detection of hearing loss and the FINGER-model. It also states that the Swedish municipalities are interested in in health promotion and prevention for residents over 65 years of age. Special coordinators with expertise in healthy lifestyle could support this work (Socialstyrelsen, 2024).

Finland

Three main strategic programmes are central to Finland’s policy of health promotion and dementia prevention. The first is the Finnish government programme 2023, called A Strong and Committed Finland: Programme of Prime Minister Petteri Orpo's Government 20 June 2023 (Goverment of Finland, 2023). This programme argues for the prevention of disease and the promotion of health and well-being in Chapter 2.3 and is to take a broad view of key societal issues in its strategic programmes to promote health and well-being among the older population. The programme covers preventive measures to reduce risk factors for chronic diseases such as dementia and advocates extending healthy life years and improving well-being (Government of Finland, 2023). The aim is to shift the focus from corrective services towards support and assistance at an earlier stage and towards prevention (Government of Finland, 2023). The government programme also claims that different chronic diseases can be prevented by reducing their risk factors.

The second programme is a range of quality recommendations to guarantee active and functional ageing and sustainable services in 2024–2027 (Social- och hälsovårdsministeriet, 2024) published in February 2024. This is an updated version of the quality recommendations to guarantee a good quality of life and improved services for older persons 2020–2023, published in 2020 by the Ministry of Social Affairs and Health. The updated quality recommendations from 2024 are primarily intended for decision-makers and managers in municipalities and local government as a tool for developing, evaluating, and implementing their services for older people. Some of the key themes in quality recommendations involve health promotion:

promoting active ageing and the working careers and functional capacity of older people
participating in voluntary work
using technology in promoting well-being
housing and age-friendly living environments

(Social- och Hälsovårdsministeriet, 2024).

The third policy document is the National Programme of Ageing 2023 (Finnish Government, 2023), which includes measures to prevent and treat dementia, for example, by creating lifestyle guidance in the well-being services counties, which were launched at the beginning of 2023 (Finnish Government, 2023). The prevention of memory symptoms and delaying the onset of dementia benefits from the FINGER model developed by the Finnish Institute for Health and Welfare (2024), a Finnish research and development institute working under the Ministry of Social Affairs and Health. The institute published a report in 2023 providing views on the state of the national memory care pathways (Pennanen, 2023). The memory service pathway model seeks to enhance the prevention of dementia symptoms, develop the early detection of dementia, improve access to services, and describe good practice in effective and seamless service provision solutions after diagnosis. The key principles are the promotion of brain health, having low-threshold services for early identification, diagnostics and timely access to treatment, and care and services based on the individual needs.

The primary guideline for good praxis is the national care guideline on memory disorders updated in December 2024. Furthermore, the elderly services are regulated by law in Finland. The key piece of legislation is the Act on Supporting the Functional Capacity of the Older Population and on Social and Health Services for Older Persons. It is frequently referred to as the Act on Care Services for Older Persons. This law was prepared to follow up the quality of services previously set in recommendations.

Åland Islands

Åland is a self-governing region of Finland. Åland follows Finnish law in some areas like state taxation and customs but has the right to pass legislation in most other areas. Examples of areas important for public health policy are local government, healthcare, the environment, culture and education.

Åland has launched a Public health strategy in 2023, Folkhälsostrategi för Åland 2023–2030 (Ålands landskapsregering, 2023). This strategy serves as a framework for identifying and prioritising specific health promotion and prevention measures. Another strategy document on Åland is the political programme for senior citizens, Ett äldrevänligt Åland 2023–2030 to prepare for, and manage, the challenges that come with an ageing population. In addition, there is an action programme for 2024–2027 adopted in February 2024. One of its measures involves reviewing and revising the governing documents that apply to older adults and elderly care. The current guidelines for dementia care (Ålands landskapsregering, 2012) will be reviewed in 2024–2027. The public health strategy in Åland is a framework that covers all areas of health. There is also a section on dementia, which extends the prevention of dementia to cover the wider preventive work at all ages.

Legislation and regulation

Structural measures with legislation and regulation at the national level allow us to cite some examples of regulating education, physical activity, smoking, alcohol, and age-friendly town planning in the Nordic countries.

School system

The Nordic countries have pursued many reforms that should be maintained and protected, such as the educational system. In the Nordic countries education is free and publicly funded. The educational system is underpinned by the tenet that everyone has the same education opportunities, regardless of the socioeconomic status (Statistia, 2024).

Tobacco

The Norwegian tobacco control policy has been developed over a number of decades, and the Norwegian Tobacco Act has been revised numerous times (Helsedirektoratet, 2023). In 2004, Norway introduced a successful smoking ban, preventing people from smoking in public buildings such as cafes and restaurants. In 2004, only 45% of daily smokers were positive about this practice, while the percentage among non-smokers was 84% (Helsedirektoratet, 2023). Attitudes have changed rapidly after these measures were introduced. The other Nordic countries soon followed suit. In Sweden, smoking was restricted in restaurants, cafes, bars, and nightclubs in 2005.

Physical activity

Legislation can affect the power of prevention measures in various ways. Finnish legislation contains provisions on the promotion of sports: the law regulates the responsibilities and cooperation of the state administration and the municipalities’ and the state’s sports funding (FINLEX, 2015). Iceland also has a fundamental sports act regulating the funding and responsibility in sports (Government of Iceland, 1998).

Alcohol

The Nordic alcohol policy has traditionally built on three key pillars: limited private profit interest, regulating access to alcohol, and high prices and taxes. This approach has sought to reduce alcohol consumption at a population level to minimise alcohol-related harm. Extensive research shows that these policy measures are both effective and cost-efficient, significantly strengthening public health and reducing negative societal impacts (Babor, 2023). Nordic countries – Finland, Norway, Sweden, Iceland, and the Faroe Islands – have state-owned alcohol retail monopolies, such as Alko in Finland (est. 1932), Vinmonopolet in Norway (est. 1922), Systembolaget in Sweden (est. 1955), Vínbúðin in Iceland (est. 1922), and Rúsdrekkasøla Landsins in Faroe Islands (est. 1992). These monopolies remove financial incentives from alcohol sales and maintain strict controls. They maintain a limited number of outlets, enforce strict age controls, and refrain from product marketing. Denmark, however, is an exception in the Nordic region with a more lenient alcohol policy (Rømer Thomsen et al., 2024). Although it has taken steps towards stricter regulation in recent years, such as raising the age limit for purchasing milder alcoholic beverages from 16 to 18, Denmark still has a more relaxed stance compared to its Nordic neighbours. Challenges faced by the alcohol monopolies include the rise of grey online markets, declining public support, and political pressures to liberalise legislation, potentially compromising public health for economic interests (Lindeman, 2024).

Practice

The actual health-promotive and preventive measures for better brain health and to avoid dementia are carried out in practice at the national, regional, and local levels. The local levels include municipalities, voluntary organisations, and healthcare centres, though this varies according to how the system is organised in each country. As many of the risk factors for dementia also apply to the prevention of other chronic diseases and concern public health, it has not been possible to obtain a complete, detailed overview of all measures against the risk of dementia. The recommendations in the WHO guidelines on risk reduction of cognitive decline and dementia also include measures at a local level to meet the varying needs (WHO, 2022). There is thus a lot of local variation and initiatives.

Practice at national level in the Nordics

This section highlights national initiatives in the Nordic countries with some country-specific examples at the structural level. Barriers are covered in the subsequent section.

Awareness campaigns

Campaigns from Iceland, Finland, and Denmark show how initiatives by governments or non-governmental organisations in the Nordic countries focus on raising public awareness of healthy lifestyles and brain health.

To increase public awareness about the impact of lifestyle on health in old age is often a practice at a structural level. One such example of prevention comes from Denmark. In 2021–2023, the Danish Alzheimer Association conducted an awareness campaign called Hjernesund. This was a public education campaign on dementia risk factors and preventive lifestyle initiatives to raise awareness of the benefits of a healthy lifestyle on brain health among the public.

The Icelandic initiative, Health Promoting Communities, strives to raise awareness of healthy ageing, and is part of the Good to Grow Older initiative by the Government of Iceland and the Ministry of Health. The campaign’s main goal is well-being for all. It is a systematic effort working right from the knowledge-gathering phase and goals creation to action plans and implementation. The initiative has a multisectoral steering group at the national level and is a collaboration across all levels of society. Health Promoting Communities aims to increase public knowledge of the importance of health promotion, togetherness, and communication between generations.

In 2023, the Finnish National Brain Health Programme was launched by the Finnish Brain Association (2023). A wide range of organisations collaborate to implement practical measures to build towards a sustainable society that supports brain health. The Finnish Brain Federation coordinates the planning and implementation in cooperation with age-group specific coordination partners, covering children and young people, people of working age, and seniors. The National Brain Health Programme is planned to be part of a wider effort and supplements existing practices.

Public health guidance and information

Spreading information and knowledge about preventive lifestyle habits for healthy old age is also important at a national level. In Norway, the helsenorge.no by Norwegian Directorate of health, and the Norwegian Institute of Public Health are central sources for the public to learn about health promotion. In addition, the Norwegian National Centre for Ageing and Health (2024) has just published a new website about dementia prevention. There is also a new initiative in Sweden by the Swedish Dementia Centre and the Fingers Brain Health Institute, which are developing the FINGER ABC platform. The upcoming FINGER ABC is a measure at national level, with the public as the target group. The goal is to provide information to the public about preventive lifestyle changes for better brain health. The FINGER model focuses on five risk-reducing factors (physical activity, healthy food, mental stimulation, social activities, and monitoring cardiovascular risk) every day to prevent dementia and cognitive decline. Finland also has a brain training website which guides towards brain-healthy routines and lifestyle changes through various activities (Muistipuisto, 2024).

Furthermore, the Danish public can find information about primary prevention of dementia at the Danish Dementia Research Centre (Nationalt Videncenter for Demens, 2024). The website offers easily accessible information about physical activity for the public in Denmark. Information about healthy lifestyle recommendations is also easily accessible in Finland. For example, the government has issued nutritional recommendations for older people (Terveyden ja hyvinvoinnin laitos, 2020), and mobility and exercise recommendations for the elderly (Äldreinstitutet, n.d.). In addition, non-governmental organisations of chronic diseases such as the Finnish Brain Association and the Finnish Diabetes Association provide information on well-being and healthy lifestyles.

Practice at local level in the Nordics

This section describes the practice at local levels for the Nordic countries with some country-specific examples at the individual level.

Voluntary organisations and NGOs

Primary prevention of dementia in the Nordic countries includes a wide range of measures implemented by municipalities and voluntary organisations. For example, the Norwegian Health Association is a voluntary organisation that is central in offering professional advice and activities at a local level. The Alzheimer Society of Finland is an NGO with funding from the Ministry of Social Affairs and Health and is the main non-governmental dementia organisation in Finland. In addition to supporting people with dementia diseases and their caregivers, the society works on promoting brain health. Finland has a wealth of brain training groups, such as Memory for Health, which promotes memory health in the Ostrobothnia region through voluntary activities, information dissemination, group activities, cognitive training, and collaboration. In Denmark, the Danish Alzheimer’s Association had a public education campaign on dementia risk factors and preventive lifestyle initiatives in 2021–2023. There were free online webinars with experts in dementia and prevention, and a Brain Health online test with personalised feedback and counselling. Similar voluntary organisations also exist in Sweden and Iceland (the Dementia Association in Sweden and the Alzheimer Association of Iceland). Voluntary organisations in all the Nordic countries offer many different options at the local level for the entire population. Examples include different types of social networks, healthy lifestyle follow-up, exercise and training, or lifestyle guidance. Primary prevention also includes training healthcare personnel to improve the quality of care, which is a major focus throughout the Nordic countries.

Table 3. Dementia organisations in the Nordic countries.

Country	Organisation	Link/Webpage
Norway	Norwegian Health Association	nasjonalforeningen.no/
Finland	Alzheimer Society of Finland	www.muistiliitto.fi/en/frontpage
Denmark	Danish Alzheimer Association	www.alzint.org/member/alzheimer-foreningen/
Sweden	Dementia Association in Sweden	www.demensforbundet.se/
Iceland	Alzheimer Association in Iceland	www.alzheimer.is

The role of municipalities and healthcare regions

The municipalities play a central role in adapting and implementing preventive health solutions.

Municipalities are required to provide health-promoting and preventive health services to the population in Norway. Serving the municipalities, Healthy Life Centres are a recommended way to organise such health services (Helsedirektoratet, 2024). A Healthy Life Centre is an interdisciplinary primary healthcare service which offers measures for people who need support to change their health behaviour and to cope with health problems (Helsedirektoratet, 2024). Healthcare centres have a patient-centred approach in strengthening the individuals’ control of health. Healthy Life Centres play a valuable role in promoting health and well-being among the population.

In Sweden, healthcare centres play a similarly crucial role in providing lifestyle advice. These centres are primary care facilities that provide a wide range of healthcare services. They are an integral part of the Swedish healthcare system, which is known for its universal coverage and high standards of care. One key focus is prevention, including such services as vaccinations, health screenings, and lifestyle counselling to help patients maintain good health and prevent the development of chronic diseases. Preventive care is seen as a crucial aspect of healthcare in Sweden, as it not only promotes individual health and well-being but also helps to reduce the burden on the healthcare system in the long term. Overall, Swedish healthcare centres are crucial in promoting the health and well-being of the population through their focus on prevention, early intervention, and comprehensive care. A Swedish example of health promotion in a vulnerable population comes from the local hospital in Angered. The LeVa-clinic is part of the Public Health Unit at the Angered hospital and aims to find new ways of providing health support and life-style counselling to residents in the north-east of Gothenburg, a part of the city with low socioeconomic status and a shorter lifespan than average. The clinic gives guidance and personal advice on food, alcohol, physical activity, and tobacco. The clinic also offers monitoring of blood pressure, blood lipids and blood sugar free of charge. The model that constitutes the LeVa-clinic has been tested and evaluated in a pilot-project (Magnusson & Hedström, 2023).

In Iceland, the prevention of social isolation and its potential negative health effects are a major focus area. Iceland also has a lot of voluntary social and exercise opportunities for older adults.

A social and health-promoting measure in Iceland is the outdoor pools, known as heitur pottur. When you turn 67 in Iceland, the official retirement age, you get free access to swimming pools, which are run by the municipalities. This has been on offer for a long time and is extremely popular. There is also a social aspect involved: many visit the pool at the same time every week to meet friends, and strangers often engage socially.

Another successful measure maintained by large municipalities in Iceland are the indoor sports facilities that are kept open during the day and are used by the older adults for walking. This often takes place in groups, organised either privately or municipally. All Nordic countries have a range of municipal or private initiatives that involve physical activity and social gatherings for older adults.

The measures and services for people with intellectual disabilities vary a great deal. In Norway, such services include exercise and fitness measures, winter camps, sports teams, walking groups, and social groups. There is room for improvement, however, in primary prevention for this subgroup.

Targeted efforts for risk groups can have a significant effect. For example, of the 290 municipalities in Sweden, 50 have common challenges among their residents aged 65+ who have a low socio-economic status. The Swedish Association for Local Authorities and Regions has initiated national collaboration and a health promotion approach for and with municipalities which are characterised by short life expectancy, low socio-economic status, and a large share of inhabitants over 65 years.

The Danish intervention model – Our Healthy Community – aims to offer an integrated approach towards health promotion and disease prevention in municipalities (Aadahl et al., 2023). The goal is to provide new tools to improve the residents’ health and well-being. The model involves political processes, residents, and professional stakeholders at all levels in shaping their own communities and municipalities (Aadahl et al., 2023), and helping individuals make sustainable lifestyle changes.

Lifestyle interventions and secondary prevention

Intervention studies so far have shown a small effect of multifactorial interventions on short-term cognitive impairment measured by neuropsychological testing. However, there is a lack of evidence on the effect of implementation of preventive measures on dementia at all, or cognitive function over a longer period. The fact that we do not know the effect of preventive measures on an individual level creates a great deal of uncertainty and makes communication about the prevention of dementia challenging.

Secondary prevention includes measures getting general practitioners and other healthcare professionals to follow up on those who have developed risk factors or already have dementia. Other examples are learning centres, wellness centres, and other bodies in municipalities and specialist health services. In a Danish initiative, the focus is on improving the physical exercise of people with dementia, supported by evidence from an ADEX study where moderate to intense exercise reduced neuropsychiatric symptoms (Hoffmann et al., 2013).

Hjärnkåren is a new day activity in Lund municipality, Sweden, for people with reduced cognitive impairment or with a cognitive diagnosis at an early stage who do not have nursing interventions from home care. Hjärnkåren is based entirely on the FINGER model and offers activities and lectures to prevent cognitive decline. The FINGER model leans on scientific evidence from the FINGER study and shows that simultaneous lifestyle measures in five areas – healthy food, physical activity, cognitive training, social activities, and cardiovascular factors – can help prevent and delay the development of cognitive decline. The project started in November 2023 and currently has 24 active participants, offering them such activities as cognitive training in the form of memory games, hydrobic, dance, a walking group, allotment cultivation, a training group, and a painting group. There are also lectures according to the five FINGER model. The aim is to contribute to improved brain health, quality of life, and increased independence according to the five FINGER model.

Age-friendly cities and communities

In recent years, the concept of age-friendly town planning has gained momentum in the Nordic countries. With an increasing older population, there is a growing recognition of the need to create urban environments that are conducive to healthy ageing and promote social inclusion for all age groups. Age-friendly Norway is one such example, a concept that aims to create a society where people of all ages can live fulfilling and active lives (Senter for aldersvennlig Norge, 2024). This involves ensuring that older adults are included and valued in all aspects of society, from access to healthcare and social services, to opportunities for leisure and social activities. This shift in perspective has led to initiatives such as improving public transportation accessibility and creating more green spaces for recreational activities. Additionally, there is a greater focus on making public buildings and facilities more age friendly. The Nordic network for age-friendly cities and communities is a collaborative initiative focused on creating age-friendly environments for older adults in the Nordic countries (Nordic Welfare Centre, 2024). The network aims to promote active ageing, social inclusion, and a high quality of life for older adults. By prioritising the needs of older residents in town planning, Nordic countries are taking proactive steps towards creating more inclusive and liveable communities for people of all ages.

Evidence vs practice

The results presented in this section include recommendations based on dialogues in workshops, interviews, on-line meeting, and other meetings between August 2023 and April 2024.

Existing evidence on the prevention of dementia risk is based on research mainly during the last 10–15 years. The Lancet Commission on Dementia Prevention, Intervention and Care has suggested modifiable risk factors for dementia (Livingston et al., 2020), and the recommendations for dementia prevention have been discussed in the WHO guidelines (2022). The Lancet model shows how lifestyle improvements have a significant effect on brain health during the life course, while the WHO provides evidence-based recommendations on lifestyle behaviours and interventions that can delay or prevent cognitive decline and dementia. Previous chapters provide examples of measures in the Nordic countries for the prevention of dementia both at local and national levels and are in line with existing evidence and recommendations. Due to a broad and comprehensive approach to dementia prevention, it has not been possible to provide a complete overview of measures. The information collated in this report reveals some areas for improvement.

The areas for improvement, or the gap between the evidence/knowledge base and the implementation of practice and measures by decision-makers and politicians seem to be both local and structural. Dementia prevention is an increasing global public health priority (WHO, 2022). However, the gap might exist because the evidence is quite new (last 10–15 years), while implementation of theory and evidence into policy and strategies takes more time. The recent report by Alzheimer’s Disease International (2024) points out the need for a long-term strategy. The report argues that the member states need to agree to a 10-year extension to the Global Action Plan to continue the work. A recent review of individual and population-based research of dementia prevention concluded that there is emerging recognition that the primary prevention of dementia, and the associated evidence, needs to consider population-level approaches (Walsh, 2023).

The evidence we have for the prevention of risk factors for dementia also has some limitations. Firstly, more evidence is needed to determine the impact that interventions on the risk factors have on the outcomes of MCI or dementia incidence (WHO, 2019). The FINGER study was the first randomised control trial to be published that demonstrates that changing several lifestyle factors can slow down cognitive decline in later life (Ngandu et al., 2015). The FINGER-study has since expanded to become a large international network (Finnish Institute for Health and Welfare, 2024).

Existing evidence is mainly based on results from a group level, which makes it difficult to recommend preventative measures to prevent disease at an individual level. The individualised prevention of dementia must build on existing knowledge, be evidence-based, and show long-term results. Life course epidemiology in research might provide the evidence we need to design preventative strategies to decrease the risk of dementia. We also need intervention strategies that target risk factors at specific timepoints during life (Wagner et al., 2024). A previous Icelandic study – Age, Gene/Environment Susceptibility-Reykjavik or AGES Reykjavik – used data to investigate whether cognitive factors related to cognitive performance were associated with the development of dementia. The results support that promoting high cognitive reserve throughout one’s life is important in reducing the dementia risk (Valsdottir et al., 2023).

“We need a deeper understanding of how dementia develops on an individual level in order to obtain clearer evidence for how to prevent dementia.”

Nordic project reference group in Helsinki, 2024

Secondly, most research is conducted in high-income countries rather than low-income countries. It might also be necessary to have country-specific information about the potential for dementia prevention due to local differences. A Danish epidemiological modelling study looking at the potential for preventing dementia in Denmark (Jorgensen, Nielsen, Nielsen, & Waldemar, 2023), indicated that risk factors such as later-life physical inactivity, hearing loss, midlife hypertension, and obesity are associated with a substantial proportion of dementia cases in Denmark. Moreover, even a partial reduction of these four risk factors could potentially have a considerable impact on the risk of developing dementia and the further prevalence of dementia in Denmark. Country-specific knowledge of dementia prevention is also important in the development of national lifestyle intervention strategies that are acceptable to the public.

According to our reference sources, there seems to be a substantial gap between the available evidence and practices in dementia prevention among people with intellectual disabilities. All evidence about dementia prevention among people with intellectual disabilities indicates that a new strategy is needed, with measures aimed at reducing the risk of dementia. Our reference sources have specified that it is time to put this target group on the agenda and that this assessment is a good start. This is a relatively large sub-group of people in the Nordic region with a high risk of developing dementia. Little research has been done on the prevention of dementia among people with intellectual disabilities or even people with Down syndrome (Strydom et al., 2018).

There has emerged a stronger interest in the issue but there must also be a greater awareness of lifestyle changes that could potentially have a preventive effect for this group. There are also certain challenges in that people with intellectual disabilities may find it hard to understand and explain their own dementia symptoms, and that healthcare personnel may have insufficient expertise in this area.

The project reference group identified four areas for improvement. The barriers and areas for improvement are discussed in the next section.

Barriers and opportunities

This section summarises the key barriers and opportunities for the implementation of preventative measures for dementia. The barriers or areas for improvements identified by our reference participants, obtained from interviews and the workshop, included four main areas:

Lack of public knowledge.
Challenges reaching out with health information to different subgroups.
Lack of financing and resources for preventative initiatives.
Competing healthcare system priorities.

The two last barriers/areas for improvement are discussed in the next section, which deals with the importance of organisational aspects.

The lack of knowledge about dementia prevention might be a barrier to the implementation of measures for the prevention of dementia in the public. In 2021 in Denmark, 54% of the public believed that they lacked the necessary knowledge to make healthier lifestyle changes (Van Asbroeck et al., 2021). One representative of the expert group pointed out that many people in Denmark do not have sufficient knowledge of the topic. An 18-month mass media campaign in Denmark between 2020 and 2021 did not increase overall awareness of dementia risk reduction but was associated with more willingness to take action to improve lifestyle and brain health (Paauw et al., 2024). A study from Norway found major gaps in existing knowledge, particularly for cardiovascular risk factors such as hypertension, coronary heart disease, hypercholesterolemia, and metabolic factors such as diabetes and obesity in a randomly selected subsample of the Norwegian population (Kjelvik et al., 2022). An Icelandic survey investigated basic knowledge about dementia prevention and found that only 8 % of the people identified a low level of education as a risk factor (Jonsdottir et al., 2022). This study demonstrated the importance of a whole-life focus in dementia risk reduction and in public health campaigns (Jonsdottir et al., 2022).

The Nordic representatives identified some key factors that are important in all societies, namely making knowledge available to different parts of the population and ensuring that the information and these methods are knowledge-based. Since the societies differ slightly, the strategies need to be tailored to the needs of each country and its health services as recommended in the WHO guidelines on risk reduction of cognitive decline and dementia (WHO, 2019).

Challenges reaching out with health information to different subgroups might also be a barrier/area for improvement for the prevention of dementia in the public. Our society has different groups of people who have different starting points for understanding about dementia prevention, for example. These groups can include immigrants, minority groups, people who are socially isolated or have low health literacy, those with a lower level of education and/or income, or people with intellectual disabilities. A barrier is reaching out to them with information and knowledge about prevention. One of the Nordic representatives said that we need good knowledge of methods and how to adapt information to reach different groups in society.

Risk factors of dementia are not equally distributed in our society. The fact is, as for other risk factors, that some groups in society have a lower ability to adopt a healthier lifestyle. There is huge potential for primary prevention measures for different subgroups, including raising awareness of the importance of lifestyle habits and implementing changes at an earlier stage. Another measure is to ensure the provision of hearing aids for those who need them, and to provide education and tailored instructions that could benefit these individuals in the long term. More emphasis on increasing cognitive reserve may, in some cases, reduce and perhaps postpone the development of dementia. Barriers include making the information comprehensible to the recipient, as well as a lack of human resources to improve the health skills among this group. Knowledge is essential for implementing appropriate and tailored measures and methods for ensuring that recipients understand the importance of changing lifestyle habits and their potential for preventing dementia.

The Nordic representatives discussed the opportunities for reaching minority or low-literacy groups with information about health promotion. They suggested health advocates or health ambassadors to identify people within smaller communities.

Importance of organisational aspects

During the Nordic–Baltic workshop, participants discussed the significance of organisational elements, such as policies, competencies, resources, management, governance models, and organisational affiliations in facilitating the implementation of preventive measures to reduce the risk of dementia. Nordic representatives highlighted both similarities and differences among countries regarding these organisational aspects in dementia prevention. They identified difficulties addressing the question of organisational aspects due to the potentially unique and country-specific nature of organisations and management models.

Government support is crucial, particularly at the highest levels. Knowledge-based policy briefs and guiding principles are needed especially when it comes to financial support and resources. A lack of resources and clear political priorities were recognised as key barriers to implementing preventative measures effectively. It is essential for governments to acknowledge and prioritise dementia, as highlighted by Alzheimer’s Disease International (2024). Politicians need to allocate resources towards preventative measures of risk factors for dementia and NCDs, because the treatment of dementia and NCDs consumes significant resources. In the European Union, NCDs are estimated to take 80% of healthcare resources, with only 3% allocated to prevention (European Commission, 2022). Legal support structures should be integrated across sectors, including health, education, the labour market, and more. Additionally, competence is central for preventative services, making guidance crucial. Lastly, more stable funding is required for volunteer work in the third sector, while enhancing collaboration with voluntary organisations in local preventative efforts.

A focus on system-level factors might be necessary to understand the big picture of dementia prevention. Researchers have found that a modifiable structural-level factor and experiencing worse healthcare quality were related to an increased risk of dementia in the next 12 years (Aravena et al., 2024). In Denmark, a publication about dementia prevention concluded that the results should inspire policymakers in Denmark to prioritise public health policies and intervention focuses on the primary prevention of dementia (Jorgensen et al., 2023). The study estimated the risk-prevention potential based on country-specific data on risk factor prevalence, and showed that physical activity, hearing loss, hypertension, and obesity could be primary targets for dementia prevention in Denmark. Since the societal costs of dementia in the Nordic countries are high (Jonsson et al., 2023), it is all the more important to aim at how dementia prevention can reduce costs to society. Preventive legislation at the municipal level may be effective, such as the public health acts have shown in Norway and Finland. The Healthy Life Centres service in Norway is organised in the municipalities and is a recommended way to organise such health services. The legal support structures should also include strengthening the integration of prevention in care.

The Nordic project reference group concluded that implementation, practice, maintenance, and evaluation should be anchored at the highest level, and at all levels. The type of governance model affects the power of the implementation of risk reduction at all levels. A population-level approach, such as a national campaign, must be organised and supported at the highest level. Legislation should ensure that it is easy for individuals to make healthy choices. A notable example from Norway is the successful smoking ban, which prohibits smoking in public buildings. This campaign resulted in a decrease in the number of smokers and demonstrated how a country can mobilise resources to promote overall health. Implementing similar laws that are both affordable and acceptable to all is crucial.

“However, when you ask if you should regulate or motivate, the thing is that you need all instruments working at the same time. When you have the promotion initiatives you must have some supporting structures in the society as well.”

Nordic project reference group in Helsinki, 2024

To sum up, the reference group recommends ensuring that national and population-oriented strategies align with local prevention efforts in organisational aspects. It is essential to develop a comprehensive prevention strategy across all sectors at the local level, while also enhancing prevention services for high-risk groups.

Conclusions

This concluding section gives recommendations to leverage and develop evidence-based and effective measures in the field of dementia prevention in the Nordics.

The fact that there are common lifestyle factors connected to prevention and risk reduction of many diseases calls for a holistic approach to dementia prevention. Considering the available research, the Nordic countries need a long-term strategy for dementia prevention clearly integrated into the work on preventing other non-communicable diseases.

Some areas of improvement in implementing measures were identified in the mapping, including the lack of awareness in the population, both overall and in more vulnerable groups. In addition, implementation of practice should focus on making healthy lifestyle choices available for everyone, promoting brain health and supporting cognitive functionality during the whole lifespan.

Organisational aspects are central in supporting the implementation of dementia-preventive measures. Taken together, there is a need for a comprehensive approach in the municipalities, good plans locally that act together with legal support structures. We need a broad prevention strategy in all local sectors, while also strengthening the provision of prevention among high-risk groups. Examples given in the report are high-risk municipalities or dementia prevention in subgroups, such as for persons with intellectual disabilities, minority groups, those with lower income levels, or people with low health literacy. The unequal distribution of social determinants of health conditions in which people are born, grow up, live, work, and age are also important factors in the regulation and legalisation efforts at a population level.

A formalised Nordic–Baltic expert network can contribute to continued knowledge sharing between the Nordic and Baltic countries on dementia prevention. A common focus on development in this novel area can leverage dementia prevention in the Nordics and Baltics in the coming years.

Recommendations for dementia prevention in the Nordics

Interaction between the prevention of dementia and the prevention of non-communicable diseases

Multiple concurrent risk factors may have a bearing on preventive measures. Common risk factors for heart and brain diseases and all NCDs are the driving force behind preventive measures in Nordic health services nationally. These measures are based on the policy and strategies described in the results section. There appears to be a general approach that links to these broader recommendations. All Nordic countries have policy documents for NCDs, and all of them take a broad approach to dementia prevention. Continued health policies in areas such as education, tobacco, and alcohol in the Nordic region are crucial to promoting healthy lifestyles among citizens.

Although all Nordic countries have strategic dementia plans, dementia prevention is tackled to varying degrees. Primary prevention is less common in the strategies than secondary and tertiary prevention. So far, none of the Nordic countries has used knowledge/evidence for dementia risk reduction as the basis for a systematic prevention strategy. National guidelines for following up on diseases that pose a risk of developing dementia, such as diabetes and cardiovascular disease, are important secondary preventative measures. In the future, the focus should be on synergies with established policy and on thinking at the population level also in dementia prevention.

Strategies need to build on existing structures and the prevention of other NCDs. Dementia prevention must be clearly integrated into the prevention of risks for NCDs. It is both synergistic and effective to promote heart and brain health within the same structures. Specific risk factors for dementia such as hearing loss and mental under stimulation should be added into the provided information and guidelines.

Prevention of dementia among people with intellectual disabilities is not specifically mentioned in any Nordic government plans or strategies. Instead, the issue appears to come up under public health and the prevention of NCDs. There must be a greater focus on this group if they are to receive the same care as everyone else, and a greater awareness of lifestyle changes that might have a preventive effect for this group. This includes healthy lifestyle counselling to combat obesity and providing a good education, physical activity, healthy food, and social inclusion. Introducing descriptions of functional consequences in various plans and strategies for the prevention of dementia may also be a way of ensuring the inclusion of all groups and appropriate adaptations.

In the same way that dementia must become a consideration in national public health initiatives, dementia prevention must be clearly integrated into the prevention of risks for NCDs.

How can the Nordic countries support each other?

Robust co-operation networks already exist between the Nordic countries. One of the Nordic representatives pointed out the importance of maintaining the existing networks in Nordic co-operation. The future of Nordic co-operation to reduce inequalities in health is outlined in a Nordic report.

“In the Nordics, public health has developed positively for many years … A major challenge for Nordic welfare is all the chronic diseases that concern lifestyle.”

Bo Könberg (2014)

This is also the case in the prevention of dementia, where efforts are required to leverage the potential for reducing the risk of chronic diseases in old age, such as dementia. We need cross-country research in the Nordic countries, such as research on dementia prevention and Down syndrome. The Nordic countries need to design indicators to compare the development of dementia, such as its prevalence and incidence across the Nordic region. The field of dementia prevention is actively sharing experiences and knowledge to promote rapid development. The Nordic countries, with their comparable populations, are closely aligned in this effort.

During the project on dementia prevention in the Nordics, Nordic and Baltic experts shared topical knowledge and examples of current preventive measures and to compile working material for this report. The meetings have provided new insights, valuable contacts, and established an informal Nordic network in this new area of public health and dementia policy. A suggestion from the network is to continue the collaboration also after the report has been published to leverage the momentum that this Nordic project has brought about. Continued co-operation of the Nordic–Baltic network for a limited time could further promote dementia prevention in the Nordic and Baltics countries in the coming years.

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