In a collaborative project including researchers from the the McCance Center for Brain Health at Mass General Hospital, a 12-item questionnaire was used to estimate risk of dementia and stroke in a group of adults aged 40 to 69 years participating in the United Kingdom Biobank (UKB). Using the Brain Care Score for individual participants at baseline, the researchers examined the association between Brain Care Scores and risk of dementia and stroke during follow-up.
The McCance Brain Care Score
The 21-point Brain Care Score (BCS) was conceptualized and developed by researchers from the McCance Center for Brain Health, including Zeina Chemali, MD, MPH, Director of Neuropsychiatry Clinics and Training in the Departments of Psychiatry and Neurology and an Associate Professor in Psychiatry and Neurology at Harvard Medical School. In order to maximize practitioner and patient engagement, the BCS was developed using a group consensus process that systematically and quantitatively combined patient feedback, expert opinion, and scientific evidence. The BCS includes common modifiable risk factors for dementia and stroke that are most widely endorsed by professional organizations and patient advocacy groups. A scoring system was designed to give more emphasis to factors hypothesized to have the strongest associations with risk for dementia and/or stroke. Risk factors such as age, family history, education level, and socioeconomic status were not included because the survey focuses only on factors that could realistically be modified by the patient or practitioner.
The BCS captures information on (1) physical, (2) lifestyle, and (3) social and emotional risk factors. The survey includes questions about blood pressure, hemoglobin A1c, cholesterol levels, Body Mass Index, and also gathers information on diet, use of alcohol, smoking, aerobic exercise, and sleep. Importantly, the BCS also asks about stress, social relationships, and meaning in life. While there is clear evidence that these socioemotional factors affect health and well-being, they are often neglected as modifiable risk factors.
The questionnaire can be filled out by the patient and/or provider. Scores on the BCS range from 0 to 21, with higher scores reflecting lower burden of risk factors for dementia and stroke.
Validation of the Brain Care Score: Risk for Dementia and Stroke
In a recent study, the research team performed the first validation of the BCS in a clinical sample, examining the association between the BCS and risk of dementia and stroke during follow-up in adults participating in the United Kingdom Biobank (UKB), a population-based, prospective cohort study of more than 500,000 participants living in the UK. The team hypothesized that a higher BCS at baseline would be associated with a lower incidence of dementia and stroke.
The BCS was calculated for 398,990 UKB participants (mean age: 57; females: 54%) at baseline. The median BCS was 12 (observed range: 1–19). There were 5,354 new cases of dementia and 7,259 new cases of stroke recorded during a median follow-up of 12.5 years.
The researchers observed a clinically relevant and statistically significant association between BCS and risk of dementia and/or stroke. For example, in participants younger than 50 years of age at enrollment, a five-point higher BCS at baseline was associated with a 59% lower risk of dementia and a 48% lower risk of stroke. Higher BCS was associated with a lower risk of dementia and stroke incidence across all age groups (<50, 50–59, >59); stronger associations were observed in the younger participants.
Next Steps
The current study demonstrates clinically relevant and statistically significant associations between the BCS at baseline and future risk of dementia and stroke in nearly 400,000 individuals participating in the UK Biobank. Given that lower Brain Care scores were associated with a higher risk of dementia and stroke across all age groups, the BSC is a tool that could be used to identify modifiable risk factors for dementia and stroke in adults. This 12-item questionnaire is a tool that is inexpensive and easy to administer and score and could easily be incorporated into primary care settings in order to help the provider and patient identify factors that need to be addressed.
Rather than focusing on risk factors that are not modifiable, such as family history or socioeconomic status, the BCS emphasizes factors that can be managed or changed. Improving one’s BCS may require medical intervention (for example, medications to manage blood pressure or cholesterol levels), but the BCS highlights behaviors that an individual may target in order to improve brain health, such as diet, exercise and use of alcohol.
Also notable is the inclusion of social and emotional factors associated with brain health, specifically asking questions about stress, social relationships, and meaning in life. Often these important modifiable risk factors are overlooked in a primary care setting.
The current study focuses only on Brain Care Scores at baseline; future studies are needed to determine how individual improvements in BCS, especially in younger adults, may modify subsequent risk for dementia and stroke.
Researchers involved in this study include Sanjula D. Singh, MD, PhD, MSc, Tin Oreskovic, MSc, Sinclair Carr, MS, Keren Papier, PhD, Megan Conroy, MSc, Jasper R. Senff, MD, Zeina Chemali, MD, MPH, Leidys Gutierrez-Martinez, MD, MSc, Livia Parodi, PhD, Ernst Mayerhofer, MD, Sandro Marini, MD, Courtney Nunley, MSc, Amy Newhouse, MD, An Ouyang, PhD, H. Bart Brouwers, MD PhD, Brandon Westover, MD, PhD, Cyprien Rivier, MD, Guido Falcone, MD, PhD, Virginia Howard, PhD, George Howard, PhD, Aleksandra Pikula, MD, Sarah Ibrahim, RN, MN, Kevin N. Sheth, MD, PhD, Nirupama Yechoor, MD, Ronald M. Lazar, MD, PhD, Christopher D. Anderson, MD, MMSc, Rudolph E. Tanzi, PhD, Gregory Fricchione, MD, Thomas Littlejohns, PhD, MSc, and Jonathan Rosand, MD, MSc.
Read More
Fernandes M, Sun H, Chemali Z, Mukerji SS, M V R Moura L, Zafar SF, Sonni A, Biffi A, Rosand J, Brandon Westover M. Brain health scores to predict neurological outcomes from electronic health records. Int J Med Inform. 2023 Dec;180:105270.
Singh SD, Oreskovic T, Carr S, Papier K, et al. The predictive validity of a Brain Care Score for dementia and stroke: data from the UK Biobank cohort. Front Neurol, Dec 2023.
Singh SD, Gutierrez-Martinez L, Newhouse A, Sonni A, Chemali Z, and Rosand J. Brain health begins with brain care. Lancet Neurol (2022) 21:961–2.
