Vascular risk reduction for brain health

Why vascular risk matters for the brain

Around a third of dementia in older adults is Mixed Alzheimer's and Vascular Dementia, and pure Vascular Dementia accounts for a further 10% to 15%. Even in pure Alzheimer's Disease, cerebrovascular changes lower the threshold at which symptoms emerge. The Lancet 2024 Commission on dementia prevention identified vascular risk factors (Hypertension, diabetes, smoking, obesity, physical inactivity, excess alcohol) as collectively responsible for around 40% of dementia cases worldwide.

In short: looking after your heart and blood vessels is the most evidence-backed thing you can do for your brain.

The six vascular levers

1. Blood pressure

UK NICE guidance (NG136) recommends a clinic blood pressure below 140/90 mmHg in adults under 80, and below 150/90 mmHg in adults aged 80 and over, with home readings typically 5 mmHg lower. For people with Type 2 Diabetes, chronic kidney disease, or established cardiovascular disease, more aggressive control (closer to 130/80) is often advised.

If your last reading was high, ask your GP for ambulatory or home blood pressure monitoring rather than a one-off check. Treatment usually begins with lifestyle change (salt reduction, weight, exercise) and is supplemented as needed with medicines such as Amlodipine, Ramipril, Indapamide or Losartan.

Action: Take three home readings most days for a week and bring the average to your next GP appointment.

2. Cholesterol and lipids

A fasting lipid profile gives total cholesterol, LDL, HDL and triglycerides, plus the TC/HDL ratio. UK targets vary by individual risk, but commonly used reference ranges are: total cholesterol below 5.0 mmol/L, LDL below 3.0 mmol/L, HDL above 1.0 mmol/L (men) or 1.2 mmol/L (women), and triglycerides below 1.7 mmol/L. For people with established cardiovascular disease, an LDL below 1.8 mmol/L is the typical target.

Statins (Atorvastatin, Simvastatin, Rosuvastatin) are the first-line medicine class. Lifestyle changes that help include reducing saturated fat, eating two to three portions of oily fish per week, increasing soluble fibre (oats, beans, lentils), and being physically active.

Action: If you have not had a lipid profile in the last twelve months, book one.

3. Blood glucose and diabetes

Type 2 Diabetes roughly doubles the risk of dementia. Even sub-diabetic levels (impaired glucose tolerance, "pre-diabetes", HbA1c 42 to 47 mmol/mol) carry increased risk. The target HbA1c in established Type 2 Diabetes is usually 48 to 53 mmol/mol, individualised. A raised random glucose level (above about 7.8 mmol/L) on an opportunistic test deserves a HbA1c follow-up.

Diabetes treatments now include Metformin, SGLT2 inhibitors (Dapagliflozin, Empagliflozin) and GLP-1 receptor agonists (Semaglutide). Some of these have shown signals of benefit beyond glucose alone, including for cognition.

Action: Ask your GP for an HbA1c if you have not had one recently, particularly if you have a family history of diabetes or are over 55.

4. Smoking

Smoking is causally linked to Vascular Dementia and accelerates the trajectory of Alzheimer's Disease. The benefit of stopping accrues quickly: cardiovascular risk halves within a year. The NHS Stop Smoking Service is free in England, Scotland and Wales, and combines counselling with nicotine replacement or Varenicline.

Action: If you smoke, contact your local stop-smoking service or use the NHS Smokefree app. There is no age at which stopping is too late to benefit.

5. Alcohol

UK Chief Medical Officers recommend no more than 14 units per week, spread over at least three days, with several alcohol-free days. Heavy drinking accelerates cognitive decline and can contribute to alcohol-related cognitive impairment, a distinct dementia subtype. Cutting back even from moderate to low intake is beneficial in MCI and early dementia.

Action: Track units for two weeks using a simple diary or an app such as Drinkaware. Discuss any concerns with your GP.

6. Weight and waist

Body mass index (BMI) in the 18.5 to 24.9 range, with a waist below 94 cm for men and below 80 cm for women, is broadly associated with better outcomes. Loss of even 5% of body weight in people with overweight or obesity meaningfully improves blood pressure, lipid profile and insulin sensitivity.

What about other contributors?

Sleep

Both short and very long habitual sleep are associated with cognitive decline. Untreated Obstructive Sleep Apnoea is a particular concern; CPAP treatment can improve daytime cognition meaningfully. If you snore loudly, have witnessed apnoeas, or feel sleepy in the day, ask your GP for a referral for a sleep study.

Hearing

Hearing loss is the single largest modifiable risk factor identified by the Lancet 2024 Commission. Wearing hearing aids when needed is associated with measurable reduction in dementia incidence. NHS hearing aids are free, and audiology assessments are available without GP referral in many areas.

Loneliness and social engagement

Persistent loneliness is associated with faster cognitive decline. Building or maintaining at least two regular social contacts each week is a realistic and protective target. See our social engagement page.

Air pollution

Long-term exposure to fine particulate air pollution is a small but consistent risk factor. Walking, exercising and ventilating away from busy roads where possible is a sensible practical step.

The vascular MOT: a 12-week plan

If you would like a structured action plan, use this 12-week framework with your GP.

• Weeks 1 to 2. Book the GP review. Take home blood pressure readings for one week. Order a fasting lipid profile and HbA1c.
• Weeks 3 to 4. Discuss the results. Agree any medication changes. Set a weight or waist target if needed.
• Weeks 5 to 8. Embed lifestyle change: 150 minutes a week of moderate-intensity exercise, Mediterranean-style eating, alcohol within limits, smoking cessation if relevant.
• Weeks 9 to 12. Re-check blood pressure at home; book a follow-up GP review at month 3 to confirm progress and tweak.

How this links to dementia treatment

If you have a diagnosis of Mixed Alzheimer's and Vascular Dementia (ICD-11 6D80.2) or Vascular Dementia (ICD-11 6D81), vascular risk reduction is not optional; it is the core treatment. Combined with a cholinesterase inhibitor where appropriate, it offers the best chance of stabilising cognition.

For people with Mild Cognitive Impairment or no diagnosis of dementia, vascular risk reduction is the most powerful preventive lever available.