September is Alzheimer’s disease awareness month. Many of you may know friends or family members who are in their seventies or older and are developing signs of mental slowing, or mild cognitive dysfunction or already have Alzheimer’s disease. I have seen the same changes in my parents as well. As Your Health Forum is all about prevention and risk reduction, this post will take a summary of dementia a step further and offer measures – all without a prescription – that can assist one who has mild cognitive dysfunction and protect others from ever developing it.
An estimated 14% of the population over 70 has signs of cognitive decline characterized by a progressive decrease in memory, processing, recall and executive function. The endpoint of this decline is dementia, or major neurocognitive disorder, as preferred by the Diagnostic and Statistical Manual of mental disorders (DSM). If you are among the fortunate ones who live to be a nonagenarian (90), an age group that now compromises about 5% of the US population and is expected to increase, there is a one in three chance that you will develop some degree of dementia – a not so fortunate prospect.
Worldwide, it is estimated that approximately 47 million people are living with dementia, mainly in developing countries. In the background of an obesity epidemic which has had the greatest toll in these countries, prevalence rates of dementia are projected to rise in the ensuing decades.
Although cognitive decline occurs with aging, it does not just suddenly begin when you hit a certain decade or birthday. Cognitive decline probably begins around middle age. In a cohort study of British civil servants, researchers detected deficits in cognitive testing even in a 45 to 49 age group when compared to their testing a decade earlier (-3.6%). The gap widened in the 65 to 75 age group, with a decline of almost 10% of their testing a decade earlier.
Your risk of dementia is not random or left to the fates. What if dementia were like a train heading toward an inevitable cliff and within our control are the accelerator and the brakes? There are several proactive measures that can reduce the velocity of decline and even stimulate new brain growth as we age.
The post will outline the mechanism of decline in the brain’s processing, along with ways in which we may preserve our brain’s health. The overarching theme is when the body is healthy, the brain is healthy.
Mechanism of Cognitive Decline and Dementia
When most people think of dementia, Alzheimer’s dementia comes to mind (no pun intended), which comprises 60-80% of cases of dementia; vascular dementia is the second most common type. The pathology of Alzheimer’s dementia involves the build-up of protein substances in the brain, beta-amyloid in senile plaques and dysfunctional tau in neurofibrillary tangles (see image below). These progressively damage the brain’s neurocircuitry and leads to brain shrinkage, or atrophy. Studies have supported that the physiology of degeneration of other forms of dementia, although each with distinguishing attributes and causes, is not that diverse from Alzheimer’s dementia and likely overlap.
What is less clear is why this occurs? Traumatic experiences, both physical (including traumatic brain injury (TBI)) and psychological, and chronic disease states have been associated with an increased risk of developing dementia. Focus will be on chronic diseases.
Beta-amyloid and other inflammatory markers are elevated substantially in insulin resistance and obesity states. Although there is a negative relation of dementia risk and higher BMI in the elderly (it may be due to higher BMI correlating with muscle mass), mid-life obesity was associated with a higher risk as BMI increases. Being overweight or obese increases the risk of developing dementia by 2.3 and 3.6-fold, respectively. Significant obesity unleashes a maelstrom of inflammatory substances including triglycerides, that increases β-amyloid production and leads to progressive changes. Obesity and all of its associated conditions, including diabetes, high blood pressure and sleep apnea, contribute to dementia.
Signs and Symptoms and Work-up of Dementia:
A person with mild cognitive impairment may develop more serious dementia over a period of several years, though more rapid decline can occur. A concept known as cognitive reserve has been shown in individuals with higher education and occupational skills, and relates to a resilience that protects one from a more rapid decline even in the face of greater pathologic changes. It is postulated that it may be related to greater neural links, i.e. greater neuroplasticity, that compensate a person.
Symptoms of dementia include short and long term memory loss, word forming issues, speech and comprehension decline, misplacing objects, confusion, agitation and change in behavior. The severity of the symptoms progress over time. What a person might initially dismiss as a part of their personality, “I can be forgetful”, transforms into a convincing deficit. The news can be devastating when a person realizes that they are going through these changes. There is also a significant stigma associated with cognitive decline and dementia.
Dementia can be assessed in the clinical setting with several screening tools. Usually a family member who suspects that their loved one is developing dementia will accompany them to the clinic visit or alert the provider. A clinician will perform a Mini-mental status exam (MMSE – below) or other screening test, take a history and a examine the patient to assess for any obvious risk factors or physical findings. The patient’s medication list will be reviewed in detail for any concerns (See Polypharmacy post). The examination will look for cardiovascular associations (carotid bruits (turbulent sounds) from increased atherosclerosis).
The clinician may order screening bloodwork (e.g. CBC with Diff, Homocysteine, methylmalonic acid, Thyroid (TSH) and RPR (screen for neurosyphilis). A blood test of amyloid precursor protein (APP) levels looks like it may be promising to be as an adjunct in the work-up for dementia with a high sensitivity. An MRI with diffusion weighted images or A PET scan of the brain may also be ordered. All of these studies can assist in making the diagnosis of dementia and rule out other causes.
Dementia-Prevention Duty! – 10 Ways to take charge:
Fortunately, there are some things that can be done to help delay, and in some cases, prevent cognitive decline that is normally associated with aging. Though it requires an important change that becomes more difficult as dementia advances – one of behavior. A healthy lifestyle may afford significant improvements in memory, mental clarity, and even emotional balance. Not included is mention of medication options or supplements. As with many things in health, prevention and addressing cognitive impairment at its earliest stages has the most effect. Get your health as optimal as possible with these simple steps and make some lasting changes to improve your brain health:
1.Keep the body moving
For such a small organ that is the brain, weighing only 3 lbs, it commands approximately 20% of the total blood supply and oxygen demand of the entire body. Improvements in aerobic capacity of the body maximize the functioning of the brain. One randomized control trial of 120 older adults showed that aerobic activity can increase the hippocampus, an area known for spatial demensions, by 2% and trigger higher levels of Brain Derived Neurotrophic Factor (BDNF), responsible for building new neural connections. Aerobic exercise increases cardiac output, not only conditioning the vessels of the body but also the brain. Increased oxygen delivery to the brain cells allows for neurogenesis and the retention of memory and critical thinking.
In addition, weight-bearing exercises, particularly with lower extremity strength building, have been shown to improve the production of neurons and create new synapses in the brain. These studies support the neuroplasticity of the brain to improve connections associated with physical movement. This can be particularly effective in those who suffer from neurodegenerative diseases such as Parkinson’s disease and Multiple Sclerosis. These patient are at increased risk of cognitive decline, directly associated with progressive mobility limitations.
2. Ensure that all senses are functioning at their best (use devices if needed)
Hearing impairment is significantly and independently linked to a greater risk of developing dementia. One study in 2011 conducted by Lin et al. showed mild, moderate and severe hearing impairment were directly associated with a 2-fold, 3-fold and 5-fold risk of dementia over a 10 year period – a “dose-dependent” association.
The mechanisms behind this are likely multiple. The auditory cortex is located at the temporal area of the brain, in the same area where the speech centers. The cochlear nerve (in the middle ear) which encodes the sound and carries the signal to the auditory cortex. The auditory cortex also linked to the thought processing, other sensory perceptions, emotion generation and speech. Imagine not being able to hear something clearly because of hearing impairment — the material cannot be retained in memory.
A progressive decline in hearing is part of aging – but can be accelerated by the impact of tympanic damage from loud noises. Unfortunately, the rates of hearing aide use have been reported to be less than 25% of those that could benefit from them.
Sure, the eyes can develop a skill such as lip-reading, which enhances auditory peripheral encoding. But — another change that occurs with aging and accelerates in dementia is visual decline. Optimizing the senses can promote maximal ability to socially interact, synthesize data and maintain learning – all of these activities preserve neural circuits and mitigates dementia.
3. Keep calm and carry on.
Unhealthy stress and trauma, be it from real or perceived psychological or physical abuse, is intimately tied to increased activation of the stress response (hypothalamic-pituatary-adrenal (HPA) axis, leading to production of cortisol by the adrenal glands. Higher levels of cortisol have been associated with memory impairment and even lower brain volumes in middle-aged adults.
The brain benefits of stress reduction techniques, such as meditation, are numerous. Most of us are aware that meditation helps to quiet the mind, clear our thinking, and reduce stress, but there is actually a change in brain chemistry that results from this. Physiological changes include:
- An increase in the production of glutathione, the “mother of all antioxidants” which has been shown to be decreased in mild cognitive impairment.
- Preservation of telomere lengths and decline at slower rate within your DNA. Stress perceived or real has been associated with telomere shortening, and hence greater cellular aging.
- A possible increase in the production of Brain Derived Neurotrophic Factor, which leads to new neural development and reduces the risk of dementia
Just a few minutes of quiet breathing per day is enough to get you started in the right track to improving and preserving cognitive ability, bolstering your cellular vitality, and improving overall health.
4. Eat like it matters
Would you put the cheapest fuel in a race car and expect top performance? Similarly, we should think this way about our bodies. However, with a third of the US population now obese, eating habits are hard to break. Convenience and comfort foods like high-carbohydrates and processed foods are linked to obesity, diabetes and atherosclerosis, hardening of the blood vessels that carry blood throughout the body – the circulation of the brain included. An increased risk (RR 1.16, without diabetes, 1.4 with) was seen in one study in patients with higher glucose levels even without diabetes. Eating a diet rich in fresh produce, whole grains, and quality proteins is ideal for optimal brain and body health, as well as promoting optimal weight. Eat like it matters, because it does.
5. Maintain social connections and healthy relationships
If you run on the introverted side (like me), it may be better for the sake of your mind to sway toward the social butterfly side. It may be related to the stimulation of conversation and neurotransmitters that shape and protect the brain. In one study, loneliness was associated with a double the risk of dementia in a four year longitudinal cohort study of 823 older persons. Brain derived neurotrophic factor (BDNF), responsible for building new neurons and neuroplasticity, increased with social interaction, as shown in an animal study. Additionally, the Harvard study showed a multitude of benefits of longevity from social connection in middle age and beyond. Those individuals that maintained rich social connections and loving relationships with family were less likely to develop dementia and other related diseases. Neurotransmitters such as dopamine, oxytocin “the love hormone”, and serotonin are likely at play. If there were any reason to maintain old friendships and develop new ones, brain health would be it. Maybe that is why one is silver and the other gold.
6. Get some sleep!
Even one night of compromised sleep can adversely affect brain chemistry. Quality sleep allows the brain to clear out toxins that naturally accumulate during the day. Researchers at Duke University studied the effects of gamblers in various states of sleep deprivation and found that those who had gotten enough sleep tended to make conservative decisions when playing. Sleep deprived players, however, made riskier decisions that ultimately resulted in the loss of both money and time that otherwise wouldn’t be spent in that atmosphere. Never underestimate the power of a good night’s sleep; it is your body’s best reset and protection against illness, disease, and aging. For more information of the importance of sleep, refer to a past submission.
7. Spend time outdoors in nature
Taking nature walks is not just good for your body; they are good for your brain as well. Taking a nature walk is not only an exercise but also a multi-sensory experience. A growing research base suggests that experiences that stimulate multiple senses often lead to improved neural circuitry, likely protecting against dementia. A reduction of stress and blood pressure are also seen – both factors related to dementia. Other benefits include improved sleep, a stronger natural immunity (natural killer cells), fewer disturbing and troublesome thoughts, and an overall sense of happiness. Even after dementia has develoed, initiatives to provide those with dementia nature hikes have shown improvements in connection and motivation.
8. Stay at a healthy weight
As stated before, research has consistently shown that those who experience weight gain or obesity in mid life are significantly more at risk for developing dementia and experiencing cognitive impairment. Conditions that are prevalent in obese individuals such as hypertension, cardiovascular disease, and diabetes all have their adverse impacts on the brain; keeping fit and healthy through the middle of your life might not always be easy, but it is essential to reduce the risk of cognitive decline.
9. Pick up an instrument or just sing along.
Music therapy for dementia can have a number of positive effects on the brain, which comes when multiple areas of the brain are recruited simultaneously. Music consists of words and rhythm, encouraging word-finding and synchronization. It evokes memory of past events associated with the music and time it was first heard as well as reduces stress. It is a social experience as well. Various reward neurotransmitters may be involved, including dopamine and serotonin. In evoking multiple brain neurocircuitry units, “neurons that fire together wire together” (Hebbian Theory). Elizabeth Stegemoeller wrote an excellent, detailed summary on neuroplasticity and the benefits of music therapy in dementia. Shout-out to Anne Tillinghast and The Backstrokes in Portland, a post-stroke and stroke awareness group with whom I have had the honor to play in their song circle. It is never too late to learn an instrument.
10. Refrain from recreational drug use
There is a lengthy body of evidence that links substance use with an increased risk of dementia. Any drug, no matter how mild it might seem (tobacco and cannabis), has the ability to interfere with the way neurons send, receive, and process signals coming from other areas of the body and within the brain. Consequently decision-making, judgement and coordination are impaired in the short term. Multiple drugs have been tied to possibly severe long-term neurocognitive dysfunction, including alcohol, cigarettes, marijuana and elicit drugs like meth and heroin. The practice of abstinence from any substance is likely a healthier decision than casual intake, but the “dose is the poison”.
Protect that brain!
Like the master switch to all of our systems, the brain is the most important resource that we have. Think of the brain as a network of sensors and effectors (i.e. receiving and sending signals). Where there is more stimulation to the body, i.e. exercise, there is greater signaling to the brain – and the brain fortifies. It is no surprise that the changes of aging, with superimposed chronic diseases, impact the brain as much as the rest of the body – (think of the blood supply needed for the brain). An optimal state of health can preserve the brain’s function throughout life. Even a health commitment at a later age can still reap rewards by reducing the velocity of cognitive dysfunction and is worth a try.
“mens sana in corpore sano”
“A sound mind in a sound body”
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