The vital need for action against the social determinants of frailty.

Dementia outcomes will increasingly reflect inequalities unless vital action is taken against the social determinants of frailty.

In Aging Medicine, Wallace and colleagues recently reported “a strong link” between a frailty index based on 41 variables of overall health and the worsening of dementia. They also found “that longitudinal changes in frailty were not significantly associated with neuropathology after controlling for possible confounders” and their results “suggest frailty is an important and modifiable risk factor for dementia” (p. 4).

The authors argue that individual interventions targeting “various factors including diet, exercise, sleep, and comorbidities … may be useful” for taking action against frailty, but consider it “likely that population‐level public health approaches that target environmental drivers of health will be the most effective” (pp. 4–5). Existing public health campaigns for dementia risk reduction continue to focus on the individual rather than the environment, which does not address differences in exposure to environmental drivers of frailty across the lifetime. The focus on individuals and their motivation to make lifestyle changes is a reflection of our age of “moralisation of health promotion” characterised by “emphasising individual responsibility for making healthier choices [and] incorporating the neoliberal values of individual choice and empowerment into policy”, which researchers would do well to resist. It is particularly important at present not to ignore the social determinants of health and health disparities because the Covid‐19 pandemic has created a perfect storm for them getting worse.

In conclusion, Wallace and colleagues’ call for a shift from individualistic interventions to public health measures against environmental drivers of frailty is both empirically supported and morally necessary. In a society with diminishing social contact, growing wealth disparities, and an overly individualistic view of responsibility for one's health, dementia outcomes will increasingly reflect inequalities unless vital action is taken against the social determinants of frailty.