How Primary Care Physicians Can Target Midlife Vascular Risk to Support Brain Health

Midlife vascular risk management may have implications that extend beyond cardiovascular disease. In a new prospective analysis of the Atherosclerosis Risk in Communities (ARIC) Neurocognitive Study, researchers found that a greater burden of vascular risk factors in midlife was associated with fewer years lived free of dementia or death. The analysis included 12 409 adults from 4 US communities who were alive and dementia-free at age 55. Investigators assessed hypertension, diabetes, and current smoking at a single midlife visit and calculated vascular risk burden based on the number of factors present. Dementia was identified through cognitive assessments, informant interviews, and continuous surveillance through 2022. Participants were followed for a median of 26.3 years, during which 3008 developed dementia and 5238 died without dementia.

Dementia-free survival declined stepwise as vascular risk accumulated. Participants with none of the 3 risk factors averaged 30.1 dementia-free survival years between ages 55 and 95, compared with 26.3 years among those with 1 risk factor, 21.0 years among those with 2, and 17.5 years among those with all 3. Compared with participants without any of the risk factors, those with all 3 had a 2.69-fold higher hazard of dementia and a 5.61-fold higher hazard of death without dementia. Because the study was observational and vascular risk was assessed at one point in midlife, the findings do not establish that modifying an individual risk factor will produce a specific gain in dementia-free survival.

In this video, corresponding author Joseph Coresh, MD, PhD, discusses how primary care physicians can translate the findings into conversations with patients in midlife. He outlines opportunities to prevent or delay hypertension and diabetes through smoking cessation, physical activity, dietary changes, weight management, and appropriate pharmacologic treatment. Coresh also reviews evidence suggesting that blood pressure treatment may reduce the risk of cognitive impairment and discusses the broader shift toward multidomain dementia prevention. The findings offer clinicians another framework for emphasizing that sustained vascular risk management may support not only cardiovascular health and longevity, but also more years of life without dementia.

Josef Coresh, MD, PhD, is the founding director of the Optimal Aging Institute and a professor of Population Health and Medicine at the NYU Grossman School of Medicine. Coresh has no relevant disclosures.

References:

1. Hu J, Coresh J, Smith JR, et al. Midlife vascular risks burden and dementia-free survival years: The Atherosclerosis Risk in Communities Neurocognitive study. Neurol Open Access. Published online August 5, 2026. doi:10.1212/WN9.0000000000000152
2. Wright JD, Folsom AR, Coresh J, et al. The ARIC (Atherosclerosis Risk In Communities) Study: JACC focus seminar 3/8. J Am Coll Cardiol. 2021;77:2939-2959. doi:10.1016/j.jacc.2021.04.035