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.
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.