Brain health isn't simply the absence of brain disease. It's about getting the most out of the brain you have, reducing the risks to it, protecting it, and — over a lifetime — building what's called cognitive reserve: a kind of brain-health pension that makes the brain more resilient to wear and tear, and to the diseases that show up later in life. The brain is our most important asset, and there's no such thing as health without brain health. It's also a genuinely plastic organ — neurons grow and build new connections in response to stimulation and experience, throughout life, not just in childhood.

That should be good news, because we're facing a serious threat. In Europe, an estimated 7–10 million people were living with dementia in 2021; that figure is projected to reach 14–20 million by 2050, driven by an ageing population, an ageing workforce, and greater care demands on families and health systems already under strain. COVID-19 made the picture worse, not better — the stress, isolation, and anxiety of the pandemic hit brain health broadly, and hit healthcare workers especially hard. We need to actively reboot brain health, not just wait for things to return to normal.

Here's the part that should give us hope: many of the risk factors driving this — low education, hearing loss, hypertension, diabetes, obesity, physical inactivity, smoking, alcohol, depression, social isolation, head trauma, pollution, and more — are modifiable, and they operate across the entire lifespan, not just in old age. We already know what's possible when we act on them: a modelling study (Mukadam et al., 2020) found that simply treating hypertension, supporting smoking cessation, and providing hearing aids could reduce dementia prevalence by 8.5% and save close to £1.9 billion a year in the UK alone. Multiply that across Europe and the numbers become genuinely transformative.

The obstacle isn't the science — it's awareness. A 2019 global survey of 70,000 people across 155 countries found that fewer than half of respondents believed there was anything they could do to reduce their dementia risk, or knew what the modifiable risk factors even were. That's the gap a public health approach to brain health needs to close, at three levels: primary prevention (public messaging and awareness for everyone, from schoolchildren to policymakers), secondary prevention (equipping at-risk groups — stressed caregivers, workers at risk of burnout, early retirees — with concrete strategies), and tertiary prevention (training the healthcare workers caring for people with dementia, so they both protect their own brain health and pass those strategies on to the people in their care).

This is, in effect, an argument that brain health can do for dementia what heart health did for heart disease: turn an abstract, frightening diagnosis into something people understand they have real agency over. But that agency has to be delivered fairly. Many of these risk factors are socially determined — shaped by income, education, and structural inequality — so a genuine brain health strategy can't stop at individual advice. It has to reach upstream, into the price of healthy food, access to exercise and green space, and whether communities are actually set up to support the behaviours we're asking people to change. Brain health for some isn't brain health for all; closing that gap is the real test of whether this approach works.

Sources: UCL, Dementia prevention strategies could save £1.9bn annually · Alzheimer's Disease International, World Alzheimer Report 2019

There is still a general sense of foreboding and hopelessness felt by doctors when it comes to treating people with dementia. Doctors dread making the diagnosis because they don’t know what to do or believe what they do won’t make any difference. Disease-modifying treatments offer new hope for the future but right now are not relevant or available for most people living with dementia. What should doctors do in the meantime to overcome the hopelessness that pervades their minds and, by a strange virus-like effect, transmits into the shocked consciousness of those newly diagnosed and their families?

Contrary to the prevailing tragedy narrative, there are many grounds for hope. Hope is about agency and pathways, and one imaginative approach that offers a way forward for doctors treating people with dementia is the concept of brain health. Brain health emphasises reducing risks and protecting the brain and can be equally applied to people with dementia. At the very least, by taking a brain health approach,  the physician can escape the prison of therapeutic hopelessness by reframing their professional goal from the frustrated wish to cure a disease to one that helps the person maintain their function and quality of life.

The brains of people with dementia are vulnerable. But their brains can be protected, and the risks to their brains can be reduced through active medical management and care. This is the principle of taking a brain health approach to dementia.  Over 50% of people with dementia are receiving inappropriate medications, leading to falls, hospitalisation, unscheduled care, and accelerating cognitive decline (Murphy et al. 2020).  Delirium, a modifiable risk factor,  can be particularly devastating for people with dementia. The community prevalence of delirium in dementia is between 22-89%, and when superimposed on dementia, it results in a doubling to tripling of the rate of cognitive decline (Fong et al. 2009; Weiner 2012). The good news is that by addressing polypharmacy through deprescribing medications, targeting medical co-morbidities and frailty, and using strategies to treat and prevent delirium, we can potentially slow dementia trajectories, adding quality of life to years. We know that better continuity of care in general practice reduces adverse events and episodes of delirium, primarily due to safer prescribing (Delgado et al. 2022).  Rethinking dementia from the perspective of brain health empowers doctors and people with dementia to focus on what they can do to reduce risk and protect the brain. 

Proactive medical care of people with dementia that promotes their brain health is achievable. And it is entirely possible that preventing delirium, deprescribing and encouraging a non-smoking, exercising, socially connected and healthy-eating cohort of baby boomers with dementia to focus on brain health could make dementia, similar to what has happened for many cancers – a chronic but more manageable condition. 

Brain health is not just for people without brain disease. Brain health is for everyone, including people living with dementia. There are things we can do to reduce risks and protect the brains of people with dementia, but this requires more, not less, medical care and attention. By reframing dementia from the perspective of brain health, there are opportunities to modify the disease course and maintain quality of life. For all these reasons, doctors should think more about how to incorporate brain health into their approaches to caring for people living with dementia.  

References

Delgado J, Evans PH, Gray DP, Sidaway-Lee K, Allan L, Clare L, Ballard C, Masoli J, Valderas JM, Melzer D. Continuity of GP care for patients with dementia: impact on prescribing and the health of patients. Br J Gen Pract. 2022 Jan 27;72(715):e91-e98. doi: 10.3399/BJGP.2021.0413. PMID: 35074796; PMCID: PMC8803082

Fong TG, Jones RN, Shi P, Marcantonio ER, Yap L, Rudolph JL, Yang FM, Kiely DK, Inouye SK. Delirium accelerates cognitive decline in Alzheimer's disease. Neurology, 2009 May 5;72(18):1570-5. doi: 10.1212/WNL.0b013e3181a4129a. PMID: 19414723; PMCID: PMC2677515

Murphy C, Dyer, AH, Lawlor B,  Kennelly SP., NILVAD Study Group, Potentially inappropriate medication use in older adults with mild-moderate Alzheimer’s disease: prevalence and associations with adverse events, Age and Ageing, Volume 49, Issue 4, July 2020, 580–587, https://doi.org/10.1093/ageing/afaa067

Weiner MF. Impact of delirium on the course of Alzheimer's disease. Arch Neurol. 2012 Dec;69(12):1639-40. doi: 10.1001/archneurol.2012.2703. PMID: 22986451

Is retirement good or bad for your brain? 

Brain Health, Ageing and  Incarceration

 

To truly grasp the harmful effects of the environment on brain health and the ageing process, one must examine the experiences of older prisoners.

The ageing prison population is a growing concern. In Ireland, 10% of individuals in custody in 2015 were over the age of 50 (Irish Prison Service, 2015). By 2023, this figure had surged to 18.2%. This marks a twofold increase in just a decade. Projections suggest that by 2030, one-third of the prison population will comprise individuals aged 50 and over.

As prisons grapple with this ageing demographic, more prisoners are dying behind bars or developing dementia during their incarceration. These are not necessarily individuals serving life sentences, but their lives are effectively curtailed due to the compounded effects of poor physical, mental, and brain health.

Despite this shift, most prisons lack adequate protocols to assess and care for inmates with mild cognitive impairment or dementia. This reflects a significant gap in addressing the needs of older prisoners.

It’s important to note that most prisons were constructed in the 18th, 19th, or early 20th centuries, with no consideration for ageing populations. These facilities are not age-friendly and often fail to accommodate the complex needs of older prisoners, including those with cognitive impairments. In many cases, the design and operations of prisons actively disadvantage older inmates.

The prison environment itself exacerbates factors that are detrimental to brain health and ageing. Loneliness, isolation, depression, poor diet, lack of cognitive and social stimulation, limited physical activity, and chronic stress are inherent to prison life. Overcrowding and substandard living conditions further compound these issues. Many prisoners also enter the system already burdened by a lifetime of adversity—poverty, poor education, mental health struggles, and substance abuse—creating a cumulative effect that accelerates brain ageing and deteriorates overall health.

Some prison systems have begun incorporating the concept of "successful ageing" as part of their rehabilitation strategies for older prisoners. Expanding this approach to include brain health offers an opportunity for broader positive change. Improving brain health should become an integral goal of prison rehabilitation systems.

What steps could be taken to promote better brain health in prisons? Significant changes are needed, including redesigning the prison environment to provide access to outdoor and green spaces, fostering social connections, and offering activities that reduce depression, loneliness, and isolation. Comprehensive training and education for prison staff on dementia care, cognitive assessment, and brain health promotion are also critical. Additionally, prisons should establish clear pathways for the assessment and care of inmates with cognitive impairments. While these changes may sound ambitious, they would provide a solid framework for improving the quality of life, rehabilitation outcomes, and overall health of prisoners.

Focusing on brain health could also influence decisions regarding continued incarceration or alternative forms of supervision and detention, paving the way for more humane and effective approaches within the prison system.

 

Overcoming Stigma in Dementia:  The Power of Kindness, Creativity and Moral Imagination

 

What a 300-year-old satirist, a fantasy novelist, and forty years of Irish psychiatry have to teach us about hope and brain health.

Kindness is being considerate, generous and respectful. Creativity is the ability to produce ideas that are original and useful. Moral imagination is something more than either alone: the ability to see an issue from another person's perspective and then put a useful idea into action in the service of others. It leans on both kindness and creativity, but it demands something further too — it requires actually listening to other voices, not just imagining them.

Nowhere has moral imagination mattered more, in my own career, than in confronting the stigma of dementia. And nowhere is that confrontation older than in a novel written nearly three hundred years ago, in a hospital named after the man who wrote it.

A 300-Year-Old Warning: Swift and the Struldbruggs

In Gulliver's Travels (1726), Jonathan Swift describes an immortal race called the Struldbruggs, marked from birth by a red dot above the left eyebrow that darkens to black as they age. Gulliver is initially thrilled at the thought of people who never die — until he learns what immortality actually means for them. They develop every disease of ageing, including, in one of the earliest and most striking literary descriptions of Alzheimer's disease, the short-term memory loss that comes with it:

"In talking, they forget the common appellation of things and the names of persons, even of those who are their nearest friends and relations…For the same reason they never can amuse themselves with reading, because their memory will not serve to carry them from the beginning of a sentence to the end…"

Worse than the illness itself was how society treated them. Once identified, the Struldbruggs were "looked upon as dead in law," stripped of their property, and excluded from public life — because, as Swift's Luggnaggians reasoned, people without the capacity to manage power would only bring ruin if allowed to keep it. It is, when you read it plainly, a description of stigma: a group marked, feared, and legally erased because of a condition they didn't choose.

Swift understood this from more than imagination. He developed dementia himself, was declared of unsound mind in 1742, and spent his final years largely unable to communicate, cared for by his cousin Martha Whiteway. He had foreseen it in verse over a decade earlier, writing of his own coming "vertigo" and failing memory. And rather than simply describing the injustice, he acted on it: he left money in his will to build "a house for fools and mad" — St Patrick's Hospital, which opened in 1759 and has never closed its doors since. Swift's story is, in miniature, the whole argument of this piece: to change stigma, you need both a vision of what's wrong and the action to do something about it.

What Stigma Actually Does

Stigma, historically, was a literal mark — a sign identifying someone as less than whole, discredited by the society around them. It reflects disapproval or a lack of respect for a person or group, and it works by othering and excluding. People living with dementia experience this today in ways that would be recognisable to a Struldbrugg.

The impact is not abstract. Stigma is stressful for the person experiencing it, activating the body's stress response, and it doesn't stay contained — it becomes internalised, or it spills over onto family members. It drives withdrawal, loneliness, isolation, depression, and a reluctance to seek help in the first place. And professional stigma compounds it: negative assumptions held by clinicians — that dementia is just normal ageing, or that nothing can be done — delay diagnosis, delay treatment, and quietly deprioritise the condition in care systems that are supposed to be helping.

A Doctor's Perspective: Forty Years of Change in Ireland

I graduated from medical school in 1980. At that time, there was no dementia advocacy in Ireland, no patient voice, no Alzheimer Society of Ireland. Dementia was called "senility," treated as an unremarkable part of ageing, and people living with it were warehoused in old Victorian asylum buildings for long-term care. In 1981, I became a registrar at St Patrick's — Swift's Hospital — where patients with behavioural and neuropsychiatric symptoms were cared for on a secure ground-floor ward.

By 1991, when I returned as a consultant psychiatrist, things had barely moved. There were few or no memory clinics, little detection or diagnosis, resistance to even scanning older people with memory loss, and no community services at all. We established the Martha Whiteway Day Hospital — named for the cousin who had cared for Swift himself — to provide day care and outreach for older people with dementia in the community. Stigma, therapeutic nihilism, and a simple lack of hope were still everywhere, even as the first symptomatic treatments for dementia were just coming over the horizon.

How deep that stigma ran became clear in a study we carried out in 1996: more than half of family members said they would not tell a relative their own diagnosis of Alzheimer's disease, for fear it would cause depression or distress. It was, almost exactly, the same stigmatising response that cancer diagnoses had provoked in the late 1960s — and cancer disclosure changed utterly within twenty years, driven by new treatments and a change in culture. Dementia has been on a similar, if slower, path since.

What Drives Stigma

A few forces keep stigma alive. Fear — dementia is, in surveys of people over 50, feared more than cancer or stroke. Ignorance and misconception — in some cultures, dementia is still attributed to witchcraft, with real consequences for how people are treated. Resistance to the idea of a "cure" — dementia remains the only condition among the ten leading causes of death without a disease-modifying therapy, and that fact alone breeds a corrosive therapeutic nihilism, especially among professionals who should know better. And beneath all of it, a lack of hope — because hope and stigma are opposing forces, and where one is absent, the other tends to fill the space.

Moral Imagination in Action: What Actually Changed It

Overcoming stigma requires exactly the moral imagination defined at the start of this piece: changing perspectives, putting yourself in someone else's position, and then acting on it through kindness, creativity, and — critically — listening to the people actually affected. In Ireland, that combination has visibly worked. From the Alzheimer Society of Ireland's founding in 1982, through the service growth of the 1990s, to Atlantic Philanthropies' major investment (2006–2015) that helped establish the Global Brain Health Institute, the National Dementia Strategy, and Understand Together, the landscape has shifted enormously — driven at every stage by advocacy and, increasingly, by people with dementia speaking for themselves rather than being spoken for.

One of the clearest demonstrations came from a training programme we ran in an acute hospital between 2016 and 2018, funded by the Genio Trust. We trained everyone — clinical staff, administrators, catering, security — and measured knowledge and attitudes before and after. Over two years, overall dementia knowledge and attitude scores rose 16%, person-centred attitudes rose 8.6%, and — the figure that matters most for this argument — hope rose 30%, with a direct statistical relationship between how much staff understood and how hopeful they felt about caring for people with dementia. The comments afterward said as much as the numbers: staff who'd worked alongside people with dementia every day for years describing, for the first time, feeling comfortable, capable, and able to help.

The Power of Hope

Hope turns out to be both an emotion and a way of thinking, operating through two linked systems. The cognitive side is conscious: having goals, the will to pursue them, and pathways for actually getting there. The emotional side runs underneath it, largely unconscious — a feeling of trust, of being cared for and connected to the world. When that emotional foundation is missing, people can feel paralysed, unable to mobilise even a clear, conscious plan. Both systems have to be working for hope to function as a real therapeutic force, for a person or for a whole society.

This is the thinking behind Understand Together, Ireland's national dementia awareness campaign, launched as part of the National Dementia Strategy to end what its own tagline called "the fear and secrecy around dementia in Ireland." It was built on evidence — surveys and focus groups with carers and people with dementia shaped every message — and co-produced with people living with the condition rather than designed for them. The results speak for themselves: by 2021, 67% of people surveyed believed most people would accept someone with dementia as a close friend, and 68% believed most people would treat them just as they would anyone else — both up from 56% in 2016. That's a real, measurable shift in public empathy over five years.

Terry Pratchett: A Modern Swift

Nearly three centuries after Swift, another satirist took up much the same fight. Terry Pratchett, often compared to Swift for the way he used fantasy to hold up a distorting mirror to the world's injustices, developed a rare form of early-onset Alzheimer's disease at 58 and died at 66. Like Swift, he had strong Trinity connections, and like Swift, he didn't just write about the condition — he campaigned on it. "Who should we tell?" he asked. "We should tell everyone." He compared the silence around dementia directly to where cancer had been forty years earlier — something people were afraid even to name, as though naming it might summon it.

A Brain Health Message of Hope

The reframing that Global Brain Health Institute pursues today — thinking about dementia through the lens of brain health rather than a brain disease — is itself a piece of moral imagination applied at scale. You can work to achieve brain health even if you have dementia; there are real, actionable things that protect the brain and reduce further risk regardless of diagnosis; and there is genuine potential to stabilise trajectories and improve wellbeing, not just manage decline. Creativity and creative practice have a real role to play in that work. Reframing dementia this way directly answers several of the drivers of stigma we started with — fear, therapeutic nihilism, and the absence of hope — by replacing them with something to actually do.

Stigma is like a limpet: it clings, and shaking it off takes sustained, deliberate effort — listening to lived experience, building collaborative advocacy, and backing all of it with research and real action, not just good intentions. Terry Pratchett, in his novel Reaper Man, put the stakes as plainly as anyone ever has:

"But we must care. For if we do not care, we do not exist. If we do not exist, then there is nothing but blind oblivion."

Three hundred years after Swift first wrote the Struldbruggs into being, that's still the whole argument. Caring is not separate from the science of brain health — it's the thing that makes all the rest of it worth doing.

 

Running on Empty: Burnout and Brain Health at Work