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World-Wide FINGER: the first global network dedicated to dementia prevention

According to the World Health Organization, there are nearly 10 million new cases of dementia every year.1 It is undeniable that we are currently facing a crisis, making dementia prevention a global public health priority. A precision prevention approach that reduces dementia risk and delays cognitive decline through multidomain lifestyle interventions is the focus of the World-Wide FINGER (WW-FINGER) network. At the Alzheimer’s Association International Conference (AAIC) 2023, Dr Alina Solomon, MD, PhD, from the University of Eastern Finland, spoke on the remarkable global expansion of the network…

‘The official launch was in 2017, we were about 5 or 6 countries at the time. We just had the World-Wide FINGER network meeting at the AAIC last Sunday and we are now 60 member countries. It’s really great to see how much interest there has been in this.’

In 2009, the proof-of-concept, randomized Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) trial (NCT01041989) was launched.2 It has been estimated that a third of dementia cases can be explained by seven modifiable lifestyle factors: diabetes, hypertension, obesity, physical inactivity, depression, smoking, and low educational attainment.3 FINGER aimed to be the first trial investigating a multi-domain intervention approach (Figure 1), to sustain cognition in elderly people at risk of dementia. A total of 2,654 participants, all considered at risk of dementia based on their Cardiovascular Risk Factors, Aging, and Dementia (CAIDE) risk score, were randomly assigned to 24 months of multidomain intervention or regular health advice. The primary endpoint of the trial was to ascertain global cognitive improvement as measured through a comprehensive neuropsychological test battery (NTB) score. The trial was a success, with the total NTB score being 25% higher in the intervention group than in the control group after the 2-year period. There is currently no pharmacological treatment that equals this. The study gained global recognition and in 2017, the WW-FINGER network was established.

Figure 1: FINGER lifestyle interventions. Over a 2-year period, the trial recommended lifestyle changes encompassing diet, exercise, cognitive training, and vascular risk monitoring.

The WW-FINGER network does not seek to replicate the original study but aims to adapt and optimize interventions to test their feasibility and efficacy in diverse cultural, geographical, and economic contexts. Whilst the fundamental goals of the interventions will be maintained (addressing diet, physical exercise, cognitive training, and vascular risk monitoring), their content and delivery should be adapted dependent on country-specific trends and challenges.

A preliminary feasibility study in Singapore, part of the longer ongoing SINGER trial (NCT05007353), identified that the FINGER interventions were well received in elderly Asian communities.4 This inspired the MIND-China trial, initiated in 2018 to investigate the intervention in rural Chinese communities, putting specific focus on reducing salt intake, a prevalent issue in China. MIND-China is running a sub-study in which it will assess blood biomarker levels, as well as using MRI to assess structural brain changes.5 If amyloid and tau levels negatively correlate with intervention adherence, this is compelling evidence to encourage lifestyle modifications to inhibit the onset of dementia neuropathology. MIND-ADmini (NCT03249688) is also conducting the first proof-of-concept trial to investigate the FINGER intervention strategy in prodromal Alzheimer’s.6

In Australia, Maintain Your Brain (MYB) (ACTRN12618000851268) is partnered with WW-FINGER, examining the implementation of an internet-based multidomain intervention, as a cost-effective approach to reach geographically isolated individuals. Dr Soloman introduced digitally enhanced E-FINGER interventions at the AAIC 2023. The use of digital tools for intervention delivery gained popularity in response to the COVID19 pandemic, which hindered trials due to participants inability to attend in-person sessions. An ancillary study of MYB published its findings this year, revealing a strong association between socio-economic status, particularly educational attainment, and engagement in online dementia prevention intervention.7 This suggests this method of intervention delivery may not be suitable for low- to middle-income countries. Finding a solution suitable for low- to- middle income countries should be prioritized, as projections indicate that these regions will experience the most significant increase in dementia prevalence by 2050.8

 

 

U.S. POINTER, supported by the Alzheimer’s Association, aims to replicate the original FINGER trial to assess the generalizability of the findings in the North American context.5 Spearheaded by a team of distinguished experts, including Dr Laura Baker, the POINTER project initiated recruitment in 2019. This 2-year, multi-centre trial plans to enrol over 2000 adults at an increased risk of cognitive decline. Additionally, sub studies supported by the National Institute on Aging will collect brain imaging MRI and PET data (POINTER-Neuroimaging), objective sleep data (POINTER-zzz) and gut microbiome data (POINTER-Microbiome). The launch of U.S. POINTER was announced at the AAIC 2017 by Dr Laura Baker, from the Wake Forest School of Medicine, and is set to be completed in 2026.

 

 

FINGER 2.0 is currently being developed to test pharmacological interventions alongside lifestyle changes. Led by Prof. Miia Kivipelto, the MET-FINGER trial (NCT05109169) will take place across the UK, Sweden, and Finland. Its primary objective is to assess the efficacy of metformin, a type 2 diabetes treatment, in conjunction with FINGER interventions among patients with a high genetic susceptibility for Alzheimer’s disease.9 Diabetes is a major risk factor for Alzheimer’s, so a combination of treatment with metformin and lifestyle interventions is hoped to delay the onset of the disease. The results from this trial will provide the basis for further FINGER 2.0 trials, as well as informing drug development.

As further positive data is gathered from ongoing trials, there is a hopeful expectation that the multidomain approach to dementia prevention may play a pivotal role in shaping global healthcare advice and slowing the anticipated increase in dementia prevalence.

Written by Hannah Elkheir

Reviewed by Juliet Lawrence

References

  1. World Health Organisation. Dementia. 15/03/2023. Accessed on 09/11/2023.
  2. Ngandu T, Lehtisalo J, Solomon A, et al. A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial.  Lancet. Mar 2015;385(9984):2255-63.
  3. Norton S, Matthews FE, Barnes DE, et al. Potential for primary prevention of Alzheimer’s disease: an analysis of population-based data. Lancet Neurol. Aug 2014;13(8):788-94.
  4. Chew KA, Xu X, Siongco P, et al. SINgapore GERiatric intervention study to reduce physical frailty and cognitive decline (SINGER)-pilot: A feasibility study.  Alzheimers Dement (N Y). Mar 2021;7(1):e12141.
  5. Kivipelto, M, Mangialasche, F, Snyder, HM, et al. World-Wide FINGERS Network: A global approach to risk reduction and prevention of dementia. Alzheimer’s Dement. Jul 2020; 16:1078–1094.
  6. Sindi S, Thunborg C, Rosenberg A, et al. Multimodal Preventive Trial for Alzheimer’s Disease: MIND-ADmini Pilot Trial Study Design and Progress. J Prev Alzheimer’s Dis. Jan 2022;9(1):30-9.
  7. Welberry HJ, Chau T, Heffernan M, et al. Factors Associated with Participation in a Multidomain Web-Based Dementia Prevention Trial: Evidence from Maintain Your Brain (MYB).  J Alzheimers Dis. 2023;92(3):959-74. 
  8. Gauthier S, Webster C, Servaes S, et al. World Alzheimer Report 2022: Life after diagnosis: Navigating treatment, care, and support.  2022. Alzheimer’s Disease International.
  9. Kivipelto M, Barbera M, de Jager CA, et al. From FINGER to MET-FINGER: metformin and lifestyle intervention for multimodal precision prevention of dementia. Alzheimer’s Dement. Dec 2022;18(S11): e061539.