Evidence-based recommendations for clinicians and public-health professionals on reducing dementia risk through managing modifiable factors
What this guideline saysGMJ summary
These updated WHO guidelines provide evidence-based recommendations for reducing the risk of cognitive decline and dementia across the life course. An estimated 57 million people globally live with dementia, with no widely accessible cure. Up to 45% of dementia risk is attributed to 14 modifiable factors including unhealthy behaviours (physical inactivity, smoking, harmful alcohol use, poor diet), health conditions (hypertension, diabetes, obesity, depression, hearing loss), and environmental exposures (air pollution).
The guidelines present 16 research questions with updated or new recommendations covering interventions to promote healthy behaviours, manage health conditions, and address environmental risk factors. Recommendations are graded using GRADE methodology and include both dementia-specific guidance and links to existing WHO clinical guidance. Key additions since the 2019 edition include new recommendations on cognitive stimulation, social activity, menopausal hormone therapy, air pollution reduction, and tailored multidomain interventions.
Implementation requires action beyond individual behaviour change, including population-level policies, multisectoral collaboration, and integration into primary care and NCD programmes. The guidelines emphasize equity considerations and adaptation to diverse cultural and resource settings, particularly in low- and middle-income countries where dementia prevalence is rising fastest.
Key pointsfor clinicians
- Cognitive training may be offered to older adults with normal cognition or mild cognitive impairment (conditional recommendation, low certainty); cognitive stimulation activities should be encouraged (conditional, very low certainty)
- Physical activity should be recommended to adults with normal cognition (strong recommendation, moderate certainty) and may be recommended to those with MCI (conditional, low certainty)
- Tobacco cessation interventions should be offered to all adults who use tobacco (strong recommendation, low certainty); quitting ≥9 years prior reduces dementia risk to levels of never-smokers
- Interventions to reduce or cease hazardous and harmful alcohol drinking may be offered (conditional, moderate certainty); no level of alcohol consumption is risk-free for cognitive health
- Healthy, balanced dietary patterns (e.g. Mediterranean-style diet) may be recommended (conditional, moderate certainty); supplementation of vitamins B and E, omega-3 PUFA, and multivitamins is NOT recommended (strong against, moderate certainty)
- Management of midlife hypertension, diabetes, dyslipidaemia, and obesity may be offered for dementia risk reduction (all conditional recommendations, very low to moderate certainty)
- Hearing aids may be offered to adults with hearing loss (conditional, low certainty); menopausal hormone therapy is NOT recommended for women ≥65 years for dementia prevention (conditional against, very low certainty)
- Reducing exposure to household and ambient air pollution (especially PM2.5) may reduce dementia risk (conditional, very low certainty); tailored multidomain interventions targeting multiple risk factors may be offered (conditional, moderate to high certainty)
Summary of generic WHO guidance and dementia-specific recommendationsextracted from the guideline
| Risk factor/intervention | Generic WHO guidance | Dementia-specific recommendation | Strength | Certainty |
|---|---|---|---|---|
| Cognitive training | Lifelong learning promoted (ICOPE, brain health position paper) | May be offered to older adults with normal cognition or MCI | Conditional | Low |
| Social activity | Social participation supported (WHO Commission on Social Connection) | May be recommended to adults with normal cognition or MCI | Conditional | Very low |
| Physical activity | Regular activity recommended (WHO PA guidelines) | Should be recommended (normal cognition); may be recommended (MCI) | Strong/Conditional | Moderate/Low |
| Alcohol reduction | No safe level; SAFER package (Global alcohol action plan) | Interventions may be offered to reduce hazardous/harmful drinking | Conditional | Moderate |
| Tobacco cessation | All tobacco users supported to quit (WHO cessation guideline) | Cessation interventions should be offered | Strong | Low |
| Healthy diet | Balanced diet recommended (WHO nutrition guidelines) | Healthy dietary pattern may be recommended | Conditional | Moderate |
| Vitamin supplements | N/A | NOT recommended (vitamins B, E, omega-3, multivitamins) | Strong against | Moderate |
| Obesity management | Management offered to all with obesity (GLP-1 guideline) | Interventions for midlife obesity may be offered; dietary restriction may be offered | Conditional | Low-Moderate |
| Diabetes management | HEARTS D guideline | Management may be offered | Conditional | Very low |
| Hypertension management | HEARTS package | Management may be offered | Conditional | Very low |
| Hearing loss | Prevention, screening, management (ICOPE) | Hearing aids may be offered | Conditional | Low |
| Menopausal hormone therapy | Used for vasomotor symptoms | NOT recommended for women ≥65 years; insufficient evidence <65 years | Conditional against | Very low |
| Air pollution | WHO air quality guidelines | Reducing household and ambient pollution may reduce risk | Conditional | Very low |
| Multidomain interventions | Holistic approach to risk factors | Tailored multidomain interventions may be offered | Conditional | Moderate-High |
What changed in this edition
- Cognitive activity: recommendation updated from 'cognitive training' to include both cognitive training (low certainty, upgraded from very low in 2019) and new recommendation for cognitive stimulation
- Social activity: new recommendation (no recommendation was made in 2019 due to insufficient evidence)
- Diet: recommendation updated from 'Mediterranean-style diet' to 'healthy, balanced dietary pattern' to be more inclusive and culturally adaptable
- Obesity: new recommendation added for dietary restriction interventions specifically
- Eight new risk factors added: air pollution, HIV, menopausal hormone therapy, multidomain interventions, sleep, stroke, traumatic brain injury, and vision impairment
- Six recommendations validated without change: alcohol reduction, dyslipidaemia, physical activity, tobacco cessation, vitamin supplementation (against)
- Expanded scope to include dementia associated with HIV, TBI, and stroke, reflecting public health relevance especially in LMIC
- Stronger emphasis on equity considerations, life-course approach, and implementation in diverse settings
- Evidence base expanded with more studies from LMIC, though high-income countries still dominate
ApplicabilityGeorgia and the region
These guidelines are highly relevant for Georgia and the South Caucasus region, where population ageing is accelerating and NCD prevalence is high. Georgia’s national NCD programme can integrate dementia risk reduction into existing platforms for hypertension, diabetes, and cardiovascular disease management within primary care. Key priorities include: strengthening screening and management of midlife cardiometabolic risk factors through the primary health care network; implementing tobacco and alcohol control policies aligned with WHO best buys; promoting physical activity and healthy diets adapted to Georgian culinary traditions (which share features with Mediterranean patterns); and addressing air pollution in urban centres like Tbilisi. The emphasis on feasible, low-cost interventions (cognitive stimulation, social engagement, hearing screening) suits resource-constrained settings. Georgia should prioritize workforce training for integrated dementia risk assessment, adaptation of tools to the Georgian language and context, and equity-focused implementation in rural areas. Regional collaboration across Armenia, Azerbaijan, and Georgia could share implementation experience and address common challenges in ageing populations.
Questions this guideline answers
What are the most important modifiable risk factors for dementia prevention?
Up to 45% of dementia cases are attributable to 14 modifiable risk factors: less education, hearing loss, hypertension, smoking, obesity, depression, physical inactivity, diabetes, social isolation, excessive alcohol consumption, traumatic brain injury, air pollution, dyslipidaemia, and vision impairment. Different factors have greatest impact at different life stages—e.g., hypertension, obesity, and hearing loss in midlife (ages 19–65); smoking, depression, social isolation, diabetes, and sensory impairments in later life (≥65 years).
Should I recommend vitamin supplements to patients to prevent dementia?
No. The guidelines make a strong recommendation AGAINST supplementation with vitamins B and E, omega-3 polyunsaturated fatty acids, and multivitamins/minerals for the specific purpose of dementia prevention in people without diagnosed deficiencies. The evidence shows no benefit and potential harms that outweigh any theoretical benefits. Focus instead on promoting a healthy, balanced dietary pattern with adequate nutrient intake through whole foods.
What is the difference between cognitive training and cognitive stimulation?
Cognitive training refers to targeted, repetitive cognitive exercises or tasks that stimulate specific cognitive domains (e.g., formalized memory or attention training programmes, often delivered by trained facilitators). Cognitive stimulation is broader, encompassing both structured activities or programmes in group/social settings and everyday activities that enhance general cognitive function—such as reading, storytelling, playing games, puzzles—especially when activities are new and challenging. Both may be beneficial, with cognitive training having slightly stronger evidence (low certainty) compared to cognitive stimulation (very low certainty).
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Other guidelines on this topic
- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- Second edition, 2026
- Replaces
- Risk reduction of cognitive decline and dementia: WHO guidelines, 2019
- Status
- Current
- Published
- 2026-07-15
- Languages
- English (original); translation note included for derivative versions
- Scope
- Adults without dementia (including those with normal cognition, mild cognitive impairment, or MCI/normal cognition with another health condition); covers prevention and risk reduction of cognitive decline and dementia through interventions targeting modifiable risk factors
- Audience
- Primary: health care providers at first- and second-level facilities (doctors, nurses, other health workers); Secondary: policy-makers, health care planners, programme managers, quality improvement teams, and the general population
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-4-012355-7
- Evidence
- GRADE-rated systematic reviews and meta-analyses; evidence profiles and evidence-to-decision frameworks for 16 research questions; scoping review to validate 6 existing recommendations; certainty of evidence ranges from very low to high depending on outcome
- Next review
- Not specified; WHO committed to regularly review and disseminate emerging evidence
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