What Can We Do to Help Prevent Alzheimer’s disease (AD)

Introduction

The other day I had a conversation with a friend, and the topic of Alzheimer’s disease (AD) came up. My friend’s opinion was basically why would I want to know I have a disease that results in steady decline in function, and lacks any disease modifying treatments? This is in large part true, there have been multiple clinical trials of both symptomatic and disease modifying drugs that failed to produce adequate results. However, this is a very limitted view and neglects the benefits of focusing on modifiable risk factors and primary prevention. We know approximately 1/3rd of AD cases are due to modifiable risk factors, and the implementation of lifestyle modification early may prevent or delay the onset of AD. 

Modifiable Risk Factors

Common modifiable risk factors for AD include hypertension, hyperlipidemia, diabetes, obesity and smoking. Management of these risk factors as early as possible may offer a preventative approach for AD. Equally important are lifestyle modifications such as physical exercise, diet, mediation/mindfulness, and social activity.

Physical Activity

Physical inactivity has a significant influence on the development of AD. Twenty-one percent of AD cases are attributable to physical inactivity. There is a significant number of studies in the literature that indicate physical activity is neuroprotective. We know one of the areas in the brain affected by physical activity is the hippocampus which is involved in memory. Exercise leads to increased neurogenesis and neuroplasticity in the hippocampus. Other benefits of exercise on the brain include increased blood flow, modulation of inflammatory markers, and increased brain-derived neurotrophic factor (BDNF). The exact definition of adequate exercise varies in the literature. Any activity that is sufficient to increase heart rate and can be sustained for 30-60 minutes is my definition. A basic example would be brisk walking for 30-60 minutes. Physical activity two times a week beginning in middle age is associated with reduced risk of AD. Aerobic exercise is associated with additional cognitive benefits including improved processing speed, attention, and memory in adults with mild cognitive impairment. This recommendation is especially important for ApoE4 carriers, as exercise is associated with reduced amyloid deposits. 

Physical activity should be a recommendation for all patients without major health concerns preventing physical activity. The earlier in life a patient begins an exercise routine the better. Some of these studies have looked specifically at starting exercise routines in middle age, but there is no reason to wait. The physical and cognitive benefits of exercise are beneficial regardless of age. It’s much easier to begin training when you are young and healthy. If you build healthy lifestyle habits earlier in life, they are likely to last as you age. Guidelines for regular exercise can be found on the American Heart Association or American College of Sports Medicine websites. 

Meditation

Meditation or mindfulness is a topic that is beginning to get more attention in the medical literature. Chronic stress is believed to effect brain structures involved in memory and may contribute to AD. Psychological stress increases oxidative stress and telomere shortening which could contribute to the neuronal loss seen in AD. Meditation has emerged as a possible way to reduce the stress associated with daily life. The techniques of mindfulness involve directing one’s attention to the present moment to reduce the stress associated with constant thinking and worrying. Randomized controlled trials (RCTs) have shown significant improvements in overall well-being and attention. Improved executive function and reduced inflammatory processes implicated in AD. Additional research and larger RCTs are needed to improve the evidence base. Given the data we currently have there is no reason to not begin mindfulness practices. The techniques are relatively simple and can be learned from a variety of sources. If you are looking for low cost options for learning mindfulness, YouTube has a variety of guided mediations available. I personally like Headspace for beginners because it provides a solid foundation, has a variety of meditation courses, and allows you to track your progress. There is a fee for access to all the courses, but the first 10 sessions are free. Whichever route you choose, spending 10-15 minutes per day practicing mindfulness will lead to a happier and healthier brain. 

Diet

A great deal of research has been conducted over the last several years on the role of diet with respect to cognition. People with high calorie diets, specifically those high in fat are at higher risk for AD. Traditional western diets high in processed carbohydrates, simple sugars, and saturated fatty acids can impact the hippocampus and memory. When Japan transitioned to western diet the incidence of AD increased. Lower calorie diets with lower saturated fat content are linked to lower oxidative stress, decreased Beta amyloid burden, and decreased inflammation. One diet with proven benefits for preventing AD is the Mediterranean diet. This diet is rich in fruits, vegetables, whole grains, olive oil, and fish. There is moderate intake of low-fat dairy products and low intake of red meat, saturated fats, and sugar. Most of the data supporting the reduce risk of AD with this diet comes from epidemiological studies. Studies have shown combining this diet with exercise further reduces the risk of AD. The Mediterranean diet is associated with better cognitive function and reduced cognitive decline. This is one specific example, but the basic principles can be applied without the need to adhere to one specific named diet. 

Some specific foods you may want to add to your diet to prevent AD include fresh berries which have the highest amounts of antioxidants among the fruits. They are also low in calories and work well in diets where weight loss is a goal. Green leafy vegetables and tomatoes have the highest nutritional value when it comes to brain health amongst the vegetables. Foods high in omega-3 fatty acids are considered to be helpful in supporting brain function. The omega-3 fatty acid most important in brain function is docosahexaenoic acid (DHA), which is mostly found in fish. The anti-inflammatory and antioxidant properties of DHA are thought to be responsible for its role in preventing AD. Patients with diagnosed AD are known to have low levels of DHA. Omega-3 fatty acids recommendations from the American Heart association for adults is to eat fish rich in omega-3s two or more times per week. If using a supplement 1-3 grams per day is an adequate dose. Over 3 grams per day, you should consult with your doctor before moving above 3 grams per day. 

Finally, curcumin which is derived from turmeric has anti-inflammatory, antioxidant, and anti-amyloid properties. There is low bioavailability of the curcumin lead to mixed results in the initial trials. A new more bioavailable form called Theracumin demonstrated positive results in a randomized double-blind placebo-controlled study on memory, attention, and amyloid plaques in older adults without dementia. 

Conclusion

While there is no guarantee that lifestyle modification alone will prevent AD, there are some promising studies indicating it plays a role in the development of this disorder. Most of these interventions are things patients can implement in their lives immediately. They will not only improve cognitive function and lower the risk of developing AD, but it will improve and potential reverse other diseases of lifestyle. 

Introduction to Mindfulness

Mindfulness never struck me as something I could see myself doing on a regular basis. For many years, I viewed the practice as something for “enlightened people” with no practical application for the average person. As the years went on and the research continued to pile up in the literature, I decided to try it out. 

There are two basic ideas to keep in mind during meditation practice. We are not aware of how our body is feeling, and we are not aware of the constant stream of thoughts occurring all day long. By bringing attention to these two things we can begin to take control of our bodies and our minds.

The process is very simple and can be performed from most locations. Ideally you want a quiet place where you will be undisturbed for 10-15 minutes. I personally like the 10-minute mediation session, and it works well if you have a busy schedule. 

To begin the process, find a chair, preferably one you can sit upright in with your feet on the floor and back straight. I like to rest my hands on my legs.

I begin the process with my eyes open, and a few deep breaths in through the nose and out through the mouth. On the 5th breath I close my eyes. I return to my normal rate and rhythm of breathing in through the nose and back out through the nose. 

Next I begin the process of performing a body scan. I like to start at the head and work my way down to the toes, noting any discomfort or tension. I will also take note of areas on the body the fell relaxed and tension free. This should take 1-2 minutes. 

If at any point thoughts pop into your head, it’s fine let them come but most importantly let them go. Do not dwell on any one particular thought, just allow them pass. 

The next step is a series of breathing exercise I learned several years ago. Start with 10 breaths in through the nose and out through the mouth, counting each one. Then perform 10 breaths in through the nose and out through the nose, again counting each one as you go. Finally, take a breath in through the nose, hold it for 5 seconds, and release it slowly through the mouth to a count of 4. This sequence of breathing exercises should be performed two times for a total of 60 breaths. This will take approximately 5-7 minutes. 

For the final 1-2 minutes do not count or breath in any particular manner just allow the mind the space to think about anything it wants to. After a minute or two bring the focus back to the body, feel the feet on the floor, and arms on you lap. Open your eyes slowly, and sit for a minute to think about what you are grateful for before starting your day. It’s an excellent way to practice some gratitude. 

The more you practice this technique the easier it will be for you. As the days go on you will experience more control over both your body and your mind. 

Chronic Inflammation And Depression

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Introduction:

Inflammation is the body’s natural response to infection or injury. It’s an important response in the acute setting but chronic inflammation can contribute to the development of diseases such as heart disease and even depression. Most psychiatrists now recognize that inflammation plays a role in depressive disorders, although it’s not an inflammatory disease. Much of the research on inflammation and depression is ongoing and will develop over time. 

Risk Factors for Inflammation

·         Childhood trauma

·         High stress levels (work, school)

·         Depression that is resistant to treatment

·         Severe anxiety

·         Obesity BMI> 30

·         Medical illness

·         Recent injury or surgery

What are some nonpharmacological things we can do to reduce inflammation and thus the risk of disease?

Complementary and alternative therapies

Lifestyle: Exercise, Healthy diet, Mindfulness practice, CBT all have anti-inflammatory effects.

N-acetylcysteine studies with 2000 mg/day improved anxiety and depressive symptoms

L-methyl folate: L-methyl folate 15 mg/day as augmentation to antidepressants

Omega-3: 1000 mg/day of omega-3 fatty acids with DHA to EPA ratio > 60% improved depressive symptoms

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