Reply to “mitigating the burden of neurological disease”

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We thank Dr Albin for raising these important issues, and providing us the opportunity for further exploration of some of the critical topics raised by our article.1 It is true that several recent studies have documented a lower than projected incidence of dementia, and some have suggested an age‐adjusted decline in dementia risk.2 One potential explanation for these unexpected findings, as raised by Dr Albin, is the success of efforts directed at reducing the risk of cerebrovascular disease (better control of hypertension and hypercholesterolemia, decreased tobacco use, etc) resulting in a reduced incidence of vascular brain injury and dementia. However, at the same time, the prevalence of both obesity and diabetes in the United States is growing unchecked, reaching epidemic levels in both younger and older patients,5 and these developments may well reverse any potential temporary gains wrought by better control of other cerebrovascular risk factors in the future. Consequently, the ability to create a model of the future prevalence of dementia incorporating these and other countervailing variables with any reliability is highly limited. In designing and executing our study, we did consider these newer findings and pondered whether to attempt just such an analysis, but it soon became apparent that it was not feasible. Instead, we elected to choose one of the best reasonably current estimates we could find, and project forward using those data based upon the future growth of the geriatric population. Forecasting is always a matter of probability versus possibility, and we still feel, all things considered, that this was the most reasonable approach, while understanding that the reality of the future may prove better (or worse) than these predictions.
It is certainly true that preventative measures for many of the neurological diseases we discussed in our article extend well beyond medical therapies, and the research we are advocating would include not only medical approaches, but also interventions such as regular exercise, weight control, promoting adequate quality and quantity of sleep, stress reduction, mental health hygiene and care, and general education as well as patient‐specific health education. Our call for increased funding of comparative effectiveness research is meant to encourage discovering not only which approaches are best, but also which are most cost‐effective, regardless of whether they are preventative or interventional, medical or other. In addition, therapeutic development and deployment for the future must, by necessity, include cost projections and some means of insuring that new treatments and preventative measures will not be priced so high that they will bankrupt the medical system, but must also preserve the essential incentives necessary to promote ongoing research and development. This will most certainly require substantive dialogue and strategic cooperation between government, the pharmaceutical industry, insurers, patients, and physicians, and this is one of the many conversations we must also be a part of.
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