2187905205_158290644d_z“My Mother’s Hands” by Ann Gordon via Flickr

Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change. (Search our health archives for her posts—calling on the expertise of medical specialists—on topics from angiography to vulvar melanoma.)

This week, Dr. Pat turns to Dr. Baxter Allen, a third-year resident in the Department of Neurology at Weill Cornell Medical College/New York–Presbyterian Hospital, for answers to the questions of a 48-year-old woman concerned about her risks for Alzheimer’s disease.

Dear Dr. Pat:

My mother is 78 and has a diagnosis of Alzheimer’s. Her sister has memory loss, and she is only 70. I am 48 and am concerned about my risk for Alzheimer’s. I have high blood pressure. I am a chef and am a bit overweight, have lots of stress, and have no time to exercise. High blood pressure and strokes run in my family as well. I haven’t seen a doctor in a year.

I know I need to take my health seriously and am ready to start. Is there anything I can do to decrease my risk of memory loss and Alzheimer’s?

Beth

 

Dr. Baxter Allen Responds:

Dear Beth:

It is very important for patients to understand their risk of developing diseases that run in their families. I applaud your foresight in asking the right questions now, while you are in relatively good health. Primary prevention, which simply means modifying risk factors to prevent disease in the future, and preventive care in general are the most important factors likely to lead to improved health. If more people start asking the kinds of questions you’re posing, we may be able to prevent, or at least significantly delay, many major diseases.

WHAT WE KNOW

Risk Factors
There are many factors that are associated with the risk of developing the disease, and around one-third of Alzheimer’s disease cases worldwide may be attributable to modifiable risk factors. The evidence linking these risk factors to the development of Alzheimer’s disease is not based on that “gold standard” of medicine, the randomized, controlled trial, in which researchers apply a treatment or intervention to one group and compare the incidence of a disease to another group that does not get the treatment or intervention. This method is also known as experiential evidence. Rather, the evidence in Alzheimer’s studies is observational (i.e., seeing what risks people have at one time point and following them over time to see if they develop the disease).

Still, as Dr. Richard Isaacson, Director of the Weill Cornell Medical Center’s Alzheimer’s Prevention Clinic, states, “While there is no magic bullet or magic pill for the prevention of Alzheimer’s disease, evidence-based and low-risk interventions have great potential to maintain our brain health.”

There are several modifiable risk factors for Alzheimer’s dementia that are associated with late-onset disease, which starts after age 65. Based on observational studies, patients with high blood pressure, diabetes or insulin resistance, high cholesterol, physical inactivity, unhealthy diet, tobacco dependence, and those who suffered from head injury were all at higher risk of dementia.

High blood pressure. Treatment of high blood pressure in midlife is associated with reduced Alzheimer-related pathology, and should decrease the risk of developing the disease. Since you currently have high blood pressure, it is important for you to work with your doctor to get this under control. There are many medications that can be used, but non-pharmacologic treatments like exercise, weight loss, and healthy diet may help as well.

Diabetes. Type 2 diabetes is associated with cognitive decline, mild cognitive impairment, and both vascular and Alzheimer’s dementia. The link between these diseases is not yet well understood. Despite the decreased risk of stroke and heart disease with better diabetes control, studies have not found a decrease in Alzheimer’s development when patients with cognitive impairment improve their glucose control. Nevertheless, improving glucose control is a good idea for your overall health.

Poor Nutrition. Many observational and prospective studies have suggested a link between nutrition and dementia. For that reason, a nutritious diet—say, the Mediterranean diet; a low-glycemic diet; low caloric intake; low to moderate alcohol consumption; and intake of omega-3 fatty acids (fish oils) may decrease the risk of developing Alzheimer’s disease. Simply increasing vegetable consumption is linked to slower cognitive decline and decreased dementia risk. Again, while these conclusions are not based on randomized, controlled studies, the risks associated with following these dietary practices are very low, and the reward may be a healthier and longer life.

Make sure you eat a balanced diet to avoid vitamin deficiencies, especially the B vitamins. Deficiencies in B12 and B1 in particular can cause significant cognitive impairment. A deficiency in either of these vitamins will not cause Alzheimer’s disease; still, such deficiences can severely impact your functional independence. Other nutritional supplements—like the antioxidants found in chocolate, coffee, and tea—have been linked to improved cognition. A recently published article in The New York Times on cocoa-derived flavinols found that high doses may improve memory and reverse age-related memory loss. Unfortunately, the dose is not what one would get from a dark chocolate bar (milk chocolate is even worse, as its processing destroys most of the antioxidants), but rather high doses available only in expensive supplements. I would wait for independent confirmation from a non-industry study before spending any money on these.

Fewer Years of Education, Less Time in the Work Force. Longer education and employment are linked to decreased incidence of Alzheimer’s disease, possibly by increasing cognitive and brain reserve, and decreasing the duration of functional dependence when dementia is developed. Read books, keep yourself stimulated mentally, and avoid prolonged idle time.

Smoking. If you’re a smoker, stop! Sit down with your primary care provider and come up with a plan to quit. Don’t do it in a month or a year; do it now. In addition to greatly increasing your risk of heart disease and stroke, there is a strong link between tobacco use and dementia. Smoking cessation will increase your overall life expectancy, and there is real hope that it will increase the number of years you live without cognitive impairment.

Lack of Exercise. A sedentary lifestyle is also linked to earlier death and earlier cognitive decline. This may be due to its effect on the circulatory system and the risk of stroke and vascular disease. I know you are very busy at work, but you have to make time for exercise. Instead of sitting at a desk, stand. Instead of driving to work, walk or bike. If you need to watch TV to relax in the evening, do it while jogging in place! Even 15 to 20 minutes a day of VIGOROUS exercise can be enough to have an impact.

Stroke. Your family history of stroke is another important risk factor for cognitive decline. While stroke does not cause Alzheimer’s disease, it can cause dementia and cognitive decline, often termed “vascular dementia.” The risk of dementia is doubled in patients who have suffered from a stroke, and this risk is even higher when pre-existing cognitive impairment is present. Many of the factors discussed above—especially lack of exercise, high blood pressure, diabetes, and smoking—are important in stroke prevention as well.

Treatments for Alzheimer’s
Currently there are no drugs that are proven to prevent Alzheimer’s disease progression once it has begun. Some medications, like donepezil and memantine, may be useful in managing symptoms, but their effects are limited.

A Recent, Two-Year Controlled Trial—a Study Worth Studying
In a recently completed two-year, randomized, controlled trial of 1,260 older adults (ages 60 to 77 years old) who were at risk for cognitive impairment and Alzheimer’s, Dr. Miia Kivipelto of the National Institute of Health and Welfare in Helsinkin, Finland, and her colleagues showed that participants who received nutritional guidance, physical exercise, cognitive training, social activities, and management of heart health risk factors rather than regular health advice alone performed better on a comprehensive cognitive exam. As Dr. Kivipelto stated, “This is the first randomized control trial showing that it is possible to prevent cognitive decline using a multi-domain intervention among older at-risk individuals. These results highlight the value of addressing multiple risk factors in improving performance in several cognitive domains. Participants told us their experience was very positive, and dropout rate only 11 percent after two years.”

So, Beth, do use the knowledge that Alzheimer’s disease has been diagnosed in family members to correct the risk factors that are under your control. Fortunately, not everything in disease risk is the result of fate. Change your habits, and you may change your life.

Dr. Baxter Allen

 

References:
Kivipelto M, et al. A Multidomain Two-Year Randomized Controlled Trial to Prevent Cognitive Impairment – the FINGER study. AAIC 2014<http://www.alz.org/aaic/_downloads/AAIC-2014-FINGER-Study.pdf>

Norton et al. Potential for primary prevention of Alzheimer’s disease: an analysis of population-based data. The Lancet Neurology – 1 August 2014 ( Vol. 13, Issue 8, Pages 788-794 )<http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(14)70136-X/abstract>

Rist PM, et al. Baseline Cognitive Function, Recurrent Stroke, and Risk of Dementia in Patients With Stroke. Stroke. Jul 2013; 44(7): 1790-1795. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3695012/

Solfrizzi V, et al. Lifestyle-related factors in predementia and dementia syndromes. Expert Rev Neurother. 2008 Jan;8(1):133-58. http://informahealthcare.com/doi/abs/10.1586/14737175.8.1.133

KJ Anstey. The influence of smoking, sedentary lifestyle and obesity on cognitive impairment-free life expectancy. Int J Epidemiol. 2014 Aug 22. pii: dyu170. http://ije.oxfordjournals.org/content/early/2014/08/22/ije.dyu170.abstract

Oboudiyat C, et al. Alzheimer’s Disease. Simin Neurol 2013; 33; 313-329.

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