Guidance
Recommendations
Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Promoting healthy lifestyles
1 Encouraging healthy behaviours
National organisations and local government departments that influence public health should continue to:
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Develop and support population-level initiatives to reduce the risk of dementia, disability and frailty by making it easier for people to:
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stop smoking
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be more physically active
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reduce their alcohol consumption
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adopt a healthy diet
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achieve and/or maintain a healthy weight.
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Use the local regulatory options and legal powers available to encourage increased adoption of healthy behaviours, and risk reduction. For example, as outlined on websites such as Healthy Places.
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Make physical activity, adopting a healthy diet and achieving and maintaining a healthy weight as accessible, affordable and acceptable as possible.
2 Integrating dementia risk reduction prevention policies
Public Health England, NHS England, relevant national third‑sector organisations and health and social care commissioners should:
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Include dementia in strategy documents aimed at preventing other non‑communicable chronic conditions (for example cardiovascular disease, type 2 diabetes, stroke and chronic obstructive pulmonary disease) see NICE's guideline on type 2 diabetes prevention: population and community-level interventions.
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Make it clear that some common unhealthy behaviours can increase the risk of dementia and that addressing those behaviours will reduce the likelihood of developing dementia and other non‑communicable chronic conditions.
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Ensure interventions and programmes to prevent non‑communicable chronic conditions state that the risk of dementia can be reduced by encouraging healthy behaviours (see recommendation 1), including reducing loneliness, by leading a physically and mentally active life.
3 Raising awareness of risk of dementia, disability and frailty
Public Health England, Health Education England and NHS England should:
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Commission national, regional and local campaigns aimed at the public and health and social care professionals to show how the risk of dementia, disability and frailty can be reduced and to promote the concept of keeping mentally and physically healthy. Campaigns should use a range of media and formats to reach as many people as possible. See NICE's guideline on type 2 diabetes prevention: population and community-level interventions.
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Use the campaigns to provide messages such as:
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Sustained ill health in old age is not inevitable. The risk of developing dementia, disability and frailty may be reduced and, for some, onset can be delayed and the severity of the conditions reduced.
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Smoking, lack of physical activity, alcohol consumption, poor diet, being overweight or obese and loneliness are all avoidable risk factors for dementia, disability and frailty.
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The earlier in life that healthy changes are made, the greater the likelihood of reducing the risk of dementia, disability and frailty.
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There are health gains that can be made by changing behaviours even in mid-life.
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Healthy behaviours are more likely to be maintained if they are built into everyday life.
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Ensure messages do not stigmatise people by suggesting that people who develop dementia, disability or frailty are at fault. Tell people that although some important risks can be reduced, there may be others such as genetic susceptibility that cannot be changed. It is still worth reducing risks where possible, even if there are unmodifiable risks, as this can increase the years spent in good health.
4 Producing information on reducing the risks of dementia, disability and frailty
Public Health England and NHS England should produce detailed information to promote specific behaviours that can improve someone's health and discourage those that can lead to poor health in later life. For example, it should:
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Encourage smokers to quit or use harm reduction measures by highlighting the immediate and long‑term benefits. In particular, make it clear that there is a link between smoking and dementia, disability and frailty.
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Show how a wide range of domestic, leisure and work activities can help people to be physically active and explain how even modest increases in physical activity, at any age, can be beneficial. Include information on how physical activity:
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reduces the risk of illness in both the short and long term, preserves memory and cognitive ability, reduces risk of falls and leads to a healthier old age, improving wellbeing and quality of life
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is enjoyable and can have social benefits
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should be a part of everyday life for a person's whole life course.
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Explain that alcohol consumption can increase the risk of dementia, disability and frailty and encourage people to reduce the amount they drink as much as possible.
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Explain that regularly consuming meals, snacks and beverages high in salt, fats and sugars is bad for health.
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Explain that a diet mainly based on vegetables, fruits, beans and pulses, wholegrains and fish, is likely to improve their health (see encourage dietary habits that reduce the risk of excess energy intake in NICE's guideline on preventing excess weight gain).
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Advise people to aim to maintain a healthy body weight (see NICE's guideline on weight management: lifestyle services for overweight or obese adults).
5 Preventing tobacco use
Local government, Public Health England, NHS England and the National Trading Standards Board should continue to develop, deliver and enforce comprehensive local tobacco control strategies, in line with current policy. They should:
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Make smoking tobacco less accessible, affordable and acceptable.
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Continue to work to prevent illegal tobacco sales.
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Enforce smoke‑free laws and tobacco display provisions.
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Extend smoke‑free policies into a wider range of public places, for example, public parks, open‑air markets and sports grounds.
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Promote, and support people to establish and maintain, smoke‑free homes and cars.
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Make all health and social care services smoke free (see NICE's guideline on tobacco: preventing uptake, promoting quitting and treating dependence).
Local authorities and clinical commissioning groups should continue to commission smoking cessation services (see recommendations on policy, commissioning and training in NICE's guideline on tobacco) and promote quitting as the best way to reduce the risks from tobacco. Services should include strategies to encourage smokers who may not be able to quit, or who do not want to quit, to switch to less harmful sources of nicotine (see the section on harm reduction in NICE's guideline on tobacco).
6 Improving the environment to promote physical activity
Local government, local enterprise partnerships, transport professionals and other organisations involved with the built and natural environment or with road safety (see who should take action?), should improve environments where people live and work to encourage and enable everyone to build physical activity into their daily lives. This should include:
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Using new and existing traffic management and highway schemes to make walking and cycling safe and attractive options (see NICE's guidelines on physical activity and the environment and physical activity: walking and cycling).
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Improving the existing built environment, and designing new developments, to promote physical activity (see NICE's guideline on physical activity and the environment).
8 Supporting people to eat healthily
Local government, Public Health England and NHS England should help and support people to eat healthily by:
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Reducing availability and promotion of foods that can contribute to an unhealthy diet. For example, by reducing or limiting the number of food outlets in a given area selling foods high in salt, saturated fat, artificial trans fats and free sugars. (See the recommendation on take-aways and other food outlets in NICE's guideline on cardiovascular disease prevention, and NICE's guideline on type 2 diabetes prevention: population and community-level interventions.)
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Helping people to understand what constitutes a healthy diet. (See NICE's guidelines on cardiovascular disease: risk assessment and reduction, including lipid modification and type 2 diabetes prevention: population and community-level interventions.)
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Improving access to affordable fruit and vegetables and information on how to prepare them.
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Encouraging supermarkets and other retailers to offer promotions, such as 2‑for‑1 deals, on fruit and vegetables.
Service organisation and delivery
9 Delivering services to promote behaviour change
Public Health England, commissioners, local authorities, providers of NHS services, NHS Health Checks and other providers of behaviour change programmes should:
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Ensure programmes to prevent non‑communicable chronic diseases share resources and expertise nationally and locally to maximise coverage and impact (see NICE's guidelines on type 2 diabetes prevention: population and community-level interventions and behaviour change: individual approaches).
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Work together to deliver services that address the needs of people with multiple risk factors as well as for those with single risk factors.
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Emphasise the need for, and help people to maintain, healthy behaviours throughout life (such as stopping smoking, being physically active, drinking less alcohol, eating healthily and being a healthy weight).
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Help people identify and address their personal barriers that prevent them from making changes to improve their health.
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Make information and services available to all (see the Equality Act 2010). Additionally, target these towards those with the greatest need whenever possible.
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Develop the NHS Health Check programme to promote opportunities in mid-life to reduce the behavioural risk factors for dementia, disability and frailty by:
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tailoring the advice component of the NHS Health Check programme for different age groups
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adding dementia prevention advice to all health checks.
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Use audit to help improve the effectiveness of services.
10 Providing accessible services
Commissioners and providers of local services should:
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Work with local communities to understand the range of services that they need to reduce the risks of dementia, disability and frailty.
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Provide services at convenient times and in easily accessible places. They should offer some outside office hours, and some in workplaces and community settings (for example, community and faith centres).
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Provide digital services to complement traditional services when appropriate.
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Provide information in a range of languages and culturally acceptable styles, and offer translation and interpretation facilities if appropriate.
11 Providing advice on reducing the risks of dementia, disability and frailty at every appropriate opportunity
Public and third sector providers (such as local authorities, leisure services, emergency services and health and social care providers) should:
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Use routine appointments and contacts to identify people at risk of dementia, disability and frailty (for example, appointments with a GP or practice nurse, when attending leisure centre classes, or visiting a community pharmacy).
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Take advantage of times in people's lives when substantial change occurs. (Examples include: retirement, when children leave home, when starting to care for older relatives or grandchildren, or during the menopause.) These are times when people may consider adopting new healthy behaviours, or may be at risk of adopting unhealthy ones.
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Whenever the opportunity arises give people advice on how to reduce the risk factors for dementia, disability and frailty or refer them to specialist services when necessary (see the recommendation on deliver very brief, brief, extended brief and high intensity behaviour change interventions and programmes in NICE's guideline on behaviour change: individual approaches).
12 Providing physical activity opportunities
Local authorities and third‑sector organisations with a responsibility for, or who support, public health services should:
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Encourage both recreational activities and active travel (for example, walking, cycling) for local journeys.
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Provide supervised activities and exercise classes and an infrastructure to support walking and cycling. They should also maintain parks and open green spaces. The aim is to help people in mid‑life to be physically active in different ways, and at different levels of intensity (see NICE's guidelines on physical activity and the environment and physical activity: walking and cycling).
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Ensure that venues provide easily accessible information for visitors using forms of active travel, such as cycle parking locations and links to local online journey planners and mapping (See NICE's guideline on walking and cycling).
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Publicise these opportunities, including where they can be found and who to contact for more information (see NICE's guidelines on physical activity: brief advice for adults in primary care, behaviour change: individual approaches and the sections on risk identification in NICE's guideline on type 2 diabetes: prevention in people at high risk).
13 Provide training
Training commissioners and providers should:
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Commission or provide training and continuing professional development programmes for local authority staff, all health and social care professionals, relevant third‑sector staff and community volunteers to help to reduce the risk factors for dementia, disability and frailty in later life. Training should include how to identify people at most risk and how to advise and support people to change behaviour (see the recommendation on deliver very brief, brief, extended brief and high intensity behaviour change interventions and programmes in NICE's guideline on behaviour change: individual approaches).
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Train participants to provide brief advice and when and how to refer people to other services to address behaviour change.
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Help participants reduce their own health risks, if necessary, by changing their own behaviour (see the section on supporting staff in secondary care and closed institutions to stop or reduce harm from smoking in NICE's guideline on tobacco; also see NICE's guideline on physical activity: brief advice for adults in primary care).
14 Leading by example in the public sector
Public sector organisations should:
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Set an example by ensuring their procurement, commissioning and other policies encourage and support healthy living. For example by:
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specifying the need to encourage a healthy diet in contracts for on‑site cafes and shops
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by restricting foods high in salt, saturated fat, artificial trans fats and free sugars and drinks high in sugar
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by providing resources and support to help employees make behavioural changes (see recommendation 15).
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15 Providing support in the workplace
All employers should:
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Develop policies and provide information and support in the workplace to help employees:
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Stop smoking (see the sections on promoting stop-smoking support, stopping smoking in secondary care services and reducing harm in NICE's guideline on tobacco).
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Be more physically active (see NICE's guideline on physical activity in the workplace).
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Improve their mental wellbeing (see NICE's guideline on mental wellbeing at work).
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Return to work after long‑term sick leave (see NICE's guideline on workplace health: long-term sickness absence and capability to work).
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Eat healthily (see the recommendation on public sector catering in NICE's guideline on cardiovascular disease prevention).
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Reduce alcohol consumption (see NICE's guideline on alcohol-use disorders: prevention).
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Terms used in this guideline
This section defines terms that have been used in a particular way for this guideline.
Acceptable
Acceptability is the extent to which a certain behaviour is considered normal and appropriate within society as a whole or within subpopulations. It is sometimes referred to as the social norm. It can be influenced by advertising, legislation, and culture.
Accessible
Accessibility is the ease with which all persons can access a commodity, facility, service or product. It includes number and location of facilities or outlets, their opening times, distance and ease of travel, and language and medium of communication.
Affordable
Affordable is the extent to which products and services are within a person's financial means to purchase. Affordability measures include the use of taxation, pricing and subsidies to deter purchase of unhealthy commodities such as foods that have a high saturated fat or sugar content, cigarettes and alcohol, and to encourage the purchase of healthier options such as foods that are low in fat and sugar.
Behaviour change programmes
Behaviour change programmes are a coordinated set of interventions, which aim to change the health behaviours of individuals, communities or whole populations.
Brief advice
Brief advice can take from 30 seconds to a couple of minutes to deliver. It is mainly about giving people information, or directing them where to go for further help. It may also include other activities such as raising awareness of risks, or providing encouragement and support for change. It follows an 'ask, advise, assist' structure. For example, brief advice on smoking would involve recording the person's smoking status and advising them that stop smoking services offer effective help to quit. Then, depending on the person's response, they may be directed to these services for additional support.
Brief interventions
Brief interventions involve spoken advice, discussion, negotiation or encouragement, with or without written or other support or follow‑up. They can be delivered by a range of primary and community care professionals. These interventions are often opportunistic, typically taking no more than a few minutes for basic advice, up to around 20 minutes for a more extended, individually‑focused discussion. They may also involve referral for further interventions or more intensive support.
Dementia
Dementia is a term used to describe a collection of symptoms including memory loss, problems with reasoning and communication, and a reduction in a person's ability to carry out daily activities such as washing, dressing and cooking. The most common types of dementia are Alzheimer's disease, vascular dementia, mixed dementia and dementia with Lewy bodies. Dementia is a progressive condition, which means that the symptoms will gradually get worse. This progression will vary from person to person and each will experience dementia in a different way – people may often have some of the same general symptoms, but the degree to which these affect each person will vary (Social Care Institute for Excellence).
Disability
Any long‑term restriction on a person's ability to perform an activity in the way, or within the range, considered normal. This may be because of limited body function or structure, or personal or environmental factors.
Frailty
Frailty typically means a person is at a higher risk of a sudden deterioration in their physical and mental health. Frailty is distinct from living with 1 or more long‑term conditions or disabilities, although there may be overlaps in their management (British Geriatric Society 2014).
Free sugars
Free sugars include table sugar (sucrose), glucose, fructose, and lactose that are added to food and beverages by manufacturers, cooks and consumers. Free sugars also include the naturally present sugars in honey, syrups, fruit juices and fruit concentrates. The term free sugars does not include the natural sugars found in non‑refined foodstuffs, such as brown rice or fruit. (Adapted from the World Health Organization definition, 2014).
Individual‑level interventions
Individual‑level intervention is used to mean an intervention that aims to help someone with a behaviour that may adversely affect their health. It can be delivered on a one‑to‑one, group or remote basis, but the focus is on creating measurable change in a specific person. This type of intervention could include a GP exercise referral programme, a community weight management class, or online application to help people monitor and change their alcohol intake.
Mid-life
Mid‑life is defined as adults aged 40 to 64 years, or those aged 39 years or under from disadvantaged populations (this group is at increased risk of ill health and more likely to develop multiple morbidities).
Non‑communicable chronic conditions
Non‑communicable chronic conditions are conditions that are not passed from person to person. This includes the 4 broad groups of non‑communicable diseases: cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes. However, this term is broader and also encompasses chronic hearing and vision conditions.
Population‑level initiatives
Population‑level initiatives are national, regional or local policies or campaigns that address the underlying social, economic and environmental conditions of a population, with the aim of improving everyone's health. This type of intervention could include population‑wide distribution of leaflets that highlight the importance of being physically active, adopting a healthy diet and being a healthy weight. It could also include taxation and legislative measures to change the availability and affordability of certain products (such as reducing the density of take‑away outlets in an area).
Resilience
Resilience is usually thought of as the ability to adapt and thrive despite experiencing adversity. A resilient person has faced challenges, such as injury or illness, and has remained mentally and physically healthy (or 'bounced back' to being mentally and physically healthy by adapting to their new situation). Resilience to dementia, disability and frailty means a person will be able to withstand or delay the onset of some or all of these conditions and remain healthy for longer.
Successful ageing
Survival to an advanced age while maintaining physical and cognitive function, functional independence and a full and active life. Ill health and disability are compressed into a relatively short period before death (Fries et al. 2011).
Third sector
The part of civil society that comprises charities, community interest companies, voluntary and community organisations, social enterprises and co‑operatives.