Lifestyle interventions for dementia prevention in low- and middle-income countries: a systematic review.

Clinical Snapshot

Key Findings

• P Value: Statistically significant for overall and exercise subgroups (exact p-values not reported in abstract); multidomain CI excludes null but is wide

• Effect Size: SMD 1.49 favouring lifestyle intervention over control (overall); SMD 1.67 for exercise subgroup; SMD 1.22 for multidomain subgroup

• Primary Outcome: Cognitive outcomes (pooled across all eligible studies using standardised mean difference)

• Nnt Or Sensitivity: NNT not calculable from SMD data alone without dichotomous outcome data; the large SMD (>1.0) across categories suggests clinically meaningful effect magnitudes if confirmed in unbiased samples, but significant publication bias necessitates caution in interpretation

• Confidence Interval: Overall: 95% CI 1.06 to 1.93; Exercise: 95% CI 1.24 to 2.11; Multidomain: 95% CI 0.22 to 2.21

Clinical Application

Exercise and multidomain interventions are generally low-cost and scalable, making them theoretically well-suited to resource-constrained LMIC health systems. However, the lack of context-specific intervention design, cultural adaptation data, and implementation science evidence limits immediate real-world applicability across diverse LMICs. Australia has a significant and growing population of older adults from LMIC backgrounds, including large Chinese-Australian, Vietnamese-Australian, and South Asian-Australian communities, who may face culturally specific barriers to dementia prevention programmes. The RACGP's 2023 Guidelines for preventive activities in general practice support lifestyle modification for cognitive health. The Dementia Australia and NHMRC frameworks emphasise culturally safe care. PBS-listed pharmacological options for MCI remain limited, reinforcing the clinical relevance of non-pharmacological approaches. TGA has not approved any pharmacological agent specifically for MCI-to-dementia prevention. These findings support investment in culturally adapted, community-based exercise and multidomain programmes for at-risk CALD (culturally and linguistically diverse) populations in Australian primary care, though the evidence base requires strengthening before formal guideline incorporation. Adults with MCI or SCD in LMIC settings, particularly where exercise-based or multidomain lifestyle programmes can be feasibly delivered. Current evidence is most directly applicable to Chinese populations given the composition of the evidence base.

Abstract

INTRODUCTION: By 2050, two-thirds of people with dementia will live in low-and-middle-income countries (LMICs). However, multimodal prevention lifestyle interventions for people at risk are being developed predominantly in higher-income countries. METHODS: We systematically reviewed randomised controlled trials (RCTs) evaluating non-pharmacological interventions in individuals with mild cognitive impairment and subjective cognitive decline in LMICs. We assessed quality using the Mixed Methods Assessment Tool, meta-analysed and synthesised evidence. RESULTS: We included 25 RCTs from six countries (most in China, n=17), involving 1304 participants. In the 15 studies with sufficient data to meta-analyse, we found significant positive effects on cognition favouring interventions (1.49 (standardised mean difference, 95% CI 1.06 to 1.93)). There was significant publication bias. We classified interventions into exercise, multidomain and arts/creative expression. Exercise (1.67, 95% CI 1.24 to 2.11, n=8) and multidomain (1.22, 95% CI 0.22 to 2.21, n=5) had replicated evidence of effectiveness. There was insufficient data to meta-analyse the arts/creative category. CONCLUSION: We propose greater consideration and investment in the development of interventions accounting for specific LMIC contexts from the outset, so they are acceptable and used by local services. PROSPERO REGISTRATION NUMBER: CRD42023403908.

References

1. 1.Espinoza Jeraldo, R. I., Zabihi, S., Miranda-Castillo, C., Marshall, C. R., & Cooper, C. (2026). Lifestyle interventions for dementia prevention in low- and middle-income countries: a systematic review. BMJ Global Health. https://doi.org/10.1136/bmjgh-2024-017630