Tagged Dementia

These Preventive Measures Might Help Delay Dementia Or Cognitive Decline

In a landmark report, scientists have endorsed three strategies for preventing dementia and cognitive decline associated with normal aging — being physically active, engaging in cognitive training and controlling high blood pressure.

This is the first time experts convened by the National Academies of Sciences, Engineering and Medicine have deemed scientific evidence strong enough to suggest that preventing dementia and age-related cognitive decline might be possible.

Seven years ago, in a separate report issued by the Agency for Healthcare Research and Quality, scientists said they couldn’t recommend any interventions to forestall or slow cognitive deterioration because state-of-the-art science at that time didn’t offer enough support.

Now there’s a considerably larger body of research to draw upon. And while findings are still far from definitive, “we found encouraging evidence that supports the value of several interventions,” said Story Landis, vice chair of the 17-member panel that prepared the report and director emeritus of the National Institute of Neurological Disorders and Stroke.

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That doesn’t mean the strategies are guaranteed to protect brain health. “You can do everything right and still get dementia in later life,” said Dr. Kenneth Langa, a panel member and professor of internal medicine, gerontology and health management and policy at the University of Michigan School of Public Health.

Nor does it mean these are the only interventions that offer promise. Managing depression, controlling diabetes and high cholesterol, engaging in social activities, getting adequate sleep, eating a healthful diet, taking disease-modifying treatments for dementia (if and when they become available) and getting enough vitamin B12 and folic acid also appear worthwhile, though more research is needed before those tactics can be formally recommended, the NAS report said.

Addressing lifestyle factors that raise the risk of cognitive impairment could help prevent more than one-third of dementia cases across the globe, according to a separate comprehensive analysis published in The Lancet on Thursday.

The NAS panel proposed that its findings be shared with the public and physicians, but stopped short of proposing a major public health campaign, citing the need for further research.

Here are insights from the report, based on interviews with panel members and outside experts:

Strategies Work In Some Cases, Not Others

As people age, mental processing becomes slower and memory becomes less reliable — a normal condition known as age-related cognitive decline.

Two of the interventions recommended in the NAS report — cognitive training and physical activity — appear to have the potential to delay age-related cognitive decline. But there’s no evidence that they can prevent dementia or mild cognitive impairment, an intermediate condition that sometimes progresses to dementia.

Managing high blood pressure is the only strategy thought to have the potential to prevent or delay the onset of Alzheimer’s disease. But it wasn’t shown to have an impact on age-related cognitive decline.

Once the hallmarks of Alzheimer’s are detected — notably amyloid beta plaques and tau tangles in the brain — some interventions might not be effective, said Dr. Ronald Petersen, a member of the NAS panel and director of the Mayo Clinic’s Alzheimer’s Disease Research Center.

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Start Early

It’s now known that biological changes associated with Alzheimer’s and related dementias begin a decade or more before any symptoms become evident. So it’s best to make recommended lifestyle changes early and sustain them over time.

“Prevention really needs to start in people who don’t show any sign of the disease — probably when people reach their 40s,” said Jeffrey Keller, director of the Institute for Dementia Research and Prevention at Louisiana State University, who was not involved in the NAS study.

Controlling high blood pressure, a strategy that helps preserve the health of blood vessels in the brain, is most effective if begun in middle age, the NAS report explained. But if you’ve reached age 65 and your blood pressure isn’t well managed, you’re still well advised to bring it under control, Landis said.

The same applies to physical activity: It’s best if you start in middle age, but becoming more active in later life is still good for your health. While it’s not yet known which type of activity is most effective, for what duration and how often it should be pursued for maximum brain benefit, walking briskly for 150 minutes a week or about 20 minutes a day is a good idea, Petersen said.

On Cognitive Training

Probably the best cognitive training you can get is a good education and ongoing mental stimulation. “There’s growing evidence that the ways in which your brain is challenged all through your life matter,” noted Langa, whose research has documented a decline in dementia rates in high-income countries over the past 25 years.

But the impact of education on brain health is very difficult to quantify. So the NAS panel endorsed cognitive training based largely on a randomized controlled trial known as Advanced Cognitive Training for Independent and Vital Elderly, which studied several thousand older adults over the course of 10 years.

ACTIVE had certified trainers work with seniors in small group sessions on various cognitive exercises for 10 sessions lasting an hour or more over five to six weeks. Feedback was an essential part of the intervention and booster sessions were offered. At 10 years, there was evidence of a positive effect on seniors’ independence and ability to perform daily tasks.

What was responsible for this effect? The training? Social interactions? Feedback? Booster sessions? All or some of the above? It’s not yet clear.

It’s important to note that the panel insisted that commercially sold computer-based brain games can’t be assumed to have the same effect. So far, research about brain games has failed to prove that this type of training improves broad-based cognitive functioning and people’s ability to function independently.

“The data supporting their efficacy just isn’t there,” said Petersen of the Mayo Clinic.

Try Several Things, Not Just One

When scientists examine the brains of people with Alzheimer’s disease, they find amyloid beta plaques and tangles, but also changes in blood vessels, evidence of microbleeds, and lesions in the brain’s white matter. “It’s mixed dementia, due to multiple factors — not just one thing,” Landis said.

The corollary: Mix it up and try several ways to reduce age-related cognitive decline or dementia, not just one.

“If we think of Alzheimer’s as a multifactorial disease, it makes sense to reduce multiple risk factors simultaneously,” said Rong Zhang, associate professor of neurology and neurotherapeutics at University of Texas Southwestern Medical Center. Zhang is also the principal investigator for a five-year study investigating whether aerobic exercise combined with intensive control of hypertension and cholesterol can help prevent Alzheimer’s. That study, the Risk Reduction for Alzheimer’s Disease trial, is currently enrolling participants at six medical centers.

“The brain is complicated and its response to interventions is complex,” Langa said. “Therefore, the more strategies that you use to try to improve the brain’s health long term, the more likely they’re going to work.”

Don’t Bother

The NAS report found no evidence supporting the use of ginkgo biloba and vitamin E, which are widely marketed to people concerned about brain health. And it questioned the value of other supplements, noting that overall dietary patterns appear more important than any single substance.

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

Categories: Aging, Navigating Aging

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Alzheimer’s Disease as an Adventure in Wonderland

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A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.

A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.Credit

In her memoir “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” Dana Walrath uses drawings and stories to chronicle three years of caregiving for her mother, Alice, who was in the middle stages of Alzheimer’s disease. The experience turned out to be a magical trip down the rabbit hole of memory loss, an outcome that inspired Dr. Walrath, a medical anthropologist who taught at the University of Vermont College of Medicine and who also studied art and writing, to share their tale.

Refusing to accept the dominant narrative of Alzheimer’s disease as a horror story, Dr. Walrath used the techniques of graphic medicine to create “Aliceheimer’s,” an 80-page, 35-picture tribute to her mother’s animated mind. Graphic medicine uses text and graphics to, as she writes in the book’s introduction, “let us better understand those who are hurting, feel their stories, and redraw and renegotiate those social boundaries.”

We spoke with Dr. Walrath to learn more about graphic medicine, how the book came into being, and what it can teach others about caring for someone with Alzheimer’s disease. Here’s an edited excerpt of our conversation.

Q.

You say that “Aliceheimer’s” found you, not the other way around. What’s the backstory of your story?

A.

After a lifetime of mutually abrasive interaction, my mother moved into my home when a lock-down memory-care unit was her only other option. The years of living together not only brought us closure, but it also integrated my disparate career threads. Medical anthropology, creative writing, visual art — who knew they were connected? I sure didn’t. But Alice must have. During dementia, she said to me, “You should quit your job and make art full time.”

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A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.

A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.Credit

Q.

What is “graphic medicine” and how did you discover the genre?

A.

I started making “Aliceheimer’s” comics before I knew that graphic medicine existed. Watching Alice — a lifelong reader who was finding straight prose too hard to track — eat up books like “Maus,” “Persepolis,” “American Born Chinese” and “Fun Home” when she lived with me, made me certain that to tell our story I wanted to use a form that a person with dementia could access. When a fellow medical anthropologist introduced me to graphic medicine, I knew I had found my tribe. The “Graphic Medicine Manifesto” defines graphic medicine as “the intersection of the medium of comics and the discourse of health care.”

Q.

Which came first: your drawings or your stories? When and how did they merge?

A.

The drawings came first. If you page through “Aliceheimer’s” looking only at the left-hand pages, you can read the original comic, a love story in pictures. I started writing short vignettes, each one in response to one of the original drawings. I began posting them on a blog until the content felt right for the intimate interior of a book.

Q.

How did the “Alice in Wonderland” theme come into play?

A.

My father had read it out loud to us as kids, and during dementia Alice and I often recited parts of it together. But the day I cut up a cheap paperback copy of “Alice in Wonderland” to depict Alice’s bathrobe, her favorite garment, I knew I had found the voice for the story. Life with dementia is filled with alternate realities and magic, both scary and uplifting. Accepting wonderland as our baseline made day to day life an adventure.

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<strong> </strong>A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.

A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.Credit

Q.

How might “Aliceheimer’s” influence the medical, artistic and caregiving communities?

A.

I would love to see “Aliceheimer’s” contribute to reframing dementia as a diversity issue. Of course there is loss involved, but the more we can see people living in this state as useful true humans who might teach us all something about living in the present, about knowing sides of our loved ones that social processes kept inaccessible, the better it will be.

I would love for the medical community to start to touch on the opportunities for closure and forgiveness that this condition might bring instead of the ongoing fight for the cure. For artistic and caregiving communities, I hope the book empowers people to tell their stories, particularly in comics form.

Q.

In “Aliceheimer’s,” you suggest new ways of thinking about Alzheimer’s. How did your mother’s memory-stealing disease open your mind?

A.

The dominant zombie story of bodies without minds strips people with dementia of their humanity and interferes with creating new kinds of familial connections. How many of us have the privilege of knowing our parents as children? Through connection we heal. Comics lead us to light because, subconsciously, we associate comics with laughter, and we need permission to laugh at sickness and not just describe it in medical terms. Laughter is respite. It opens new possibilities for how to cope.

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A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.

A page from “Aliceheimer’s: Alzheimer’s Through the Looking Glass,” by Dana Walrath.Credit

Q.

What suggestions do you have for people caring for a loved one with Alzheimer’s?

A.

Learn to read the signs and messages embedded in your loved one’s actions. Often what looks delusional is an attempt to express a deeply felt need or desire. Dementia has them communicating through a code that we can track. Use the “Yes, and” principle from improv — in which you accept what the other person has said (“yes”) and then expand on that line of thinking (“and”) — to build on what your loved one is experiencing instead of contradicting them, and it will be easier to decipher his or her intentions.

Dementia lets all of us connect back to our deepest memories, to a time when we could communicate — give and receive stories — through the looks in each other’s eyes, through touch, facial expressions, actions and gestures. In this way, even in the midst of loss, dementia lets us heal.

Heartburn Drugs Tied to Dementia Risk

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The popular heartburn drugs known as proton pump inhibitors have been linked to a range of ills: bone fractures, kidney problems, infections and more. Now a large new study has found that they are associated with an increased risk for dementia as well.

Proton pump inhibitors, or P.P.I.s, are widely available both by prescription and over the counter under various brand names, including Prevacid, Prilosec and Nexium.

German researchers, using a database of drug prescriptions, studied P.P.I. use in 73,679 men and women older than 75 who were free of dementia at the start of the study. Over an average follow-up period of more than five years, about 29,000 developed Alzheimer’s disease or other dementias. The study is in JAMA Neurology.

After controlling for age, sex, depression, diabetes, stroke, heart disease and the use of other medicines, they found that regular use of P.P.I.s increased the risk for dementia in men by 52 percent and in women by 42 percent, compared with nonusers.

“Our study does not prove that P.P.I.s cause dementia,” said the senior author, Britta Haenisch of the German Center for Neurodegenerative Diseases. “It can only provide a statistical association. This is just a small part of the puzzle.

“Clinicians, pharmacists and patients have to weigh the benefits against the potential side effects,” she continued, “and future studies will help to better inform these decisions.”

To Reduce the Risk of Alzheimer’s, Eat Fish

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Salmon for sale at the Tsukiji fish market in Tokyo, Japan.

Salmon for sale at the Tsukiji fish market in Tokyo, Japan.Credit Kevin Miyazaki for The New York Times

Eating seafood is linked to a reduced risk of dementia-associated brain changes in people who carry the ApoE4 gene variation, which increases the risk for Alzheimer’s disease. Eating seafood was not linked to similar changes in those who carried other forms of the ApoE gene.

The study, published in JAMA, looked at 286 autopsied brains and also found that eating seafood was linked to increased mercury in the brain, but that mercury levels were not linked to brain abnormalities.

After controlling for age, sex, education and other factors, the researchers found that compared with those who ate less seafood, ApoE4 carriers who had one seafood meal or more a week had lower densities of the amyloid plaques and neurofibrillary tangles typical of Alzheimer’s disease. Over all, they had a 47 percent lower likelihood of having a post-mortem diagnosis of Alzheimer’s.

Consumption of fish oil supplements was not correlated with pathological brain changes.

The lead author, Martha Clare Morris, a professor of epidemiology at Rush University, said that mercury from fish appears to pose little risk for aging people. But, she said, there are studies that show that mercury consumption in pregnancy can cause cognitive problems in babies.

“Most studies in dementia have found that one seafood meal a week is beneficial,” she said, though “they haven’t found that the more you eat, the lower the risk.”