Building Brain Health
Effective treatments for dementia remain elusive but diet,
exercise and an engaged mind can help preserve brain function.
By Heather Millar
Yesterday, you misplaced your keys—again—and found them in the fridge. Today, you stared blankly at the checkbook, wondering how to compute a new balance.
“Anyone can have an off day or two,” you tell yourself. But you’re really starting to worry: Is your mind slipping?
Only cancer frightens aging baby boomers more than the prospect of memory loss, according to a 2011 MetLife Foundation survey. Approximately one out of four people older than age 65 have some kind of memory problem. Estimates vary, but as many as 5.1 million may have Alzheimer’s and that number is expected to double, perhaps even triple, by 2050.
Despite the staggering statistics, there is hope. Recent studies show you can take steps that may reduce your risk of Alzheimer’s and other forms of dementia.
Alzheimer’s and Other Ills
Alzheimer’s disease apparently occurs when an excess of a protein called amyloid beta builds up in the brain. Scientists believe that amyloid accumulations called plaques and tangles interfere with communication between neurons, causing problems with thinking, remembering and reasoning. In one study, people who showed signs of significant amyloid deposits were more likely to perform poorly on cognition tests (Neurology 8/24/11 online).
About 70% of dementia diagnoses are classified as Alzheimer’s, making it the most common form of age-related mental decline. Alzheimer’s generally begins as a gradual loss of memory and cognition that may last as briefly as two years or as long as 20. The patient first becomes forgetful and eventually loses the capacity to perform even such routine tasks as driving, cooking, using the telephone or managing finances. In addition, people with early signs of Alzheimer’s have been found to suffer falls at a greater rate.
Sophisticated genetic and imaging technologies are allowing scientists to detect changes in the brain that increase Alzheimer’s risk. For example, a study in the Journal of Neuroscience found a link between Alzheimer’s and a specific variation, known as an allele, of a gene that codes for a key factor in cholesterol metabolism called apolipoprotein E.
Other types of dementia include:
• Vascular, which occurs when someone suffers from numerous tiny strokes. This form affects about 20% of dementia patients and may be combined with Alzheimer’s. Vascular dementia randomly takes out bits and pieces of a person’s ability to function, making it tricky to diagnose and to treat. People who live in the southeastern US, where people die of strokes at a significantly higher rate than elsewhere in the country, also show higher rates of cognitive impairment (Annals of Neurology 5/26/11 online).
• Alcoholic, which results from alcohol abuse. Both the very young and the very old are much more susceptible to the harmful effects of drinking than other people.
• Lewy body, which stems from protein deposits that throw the brain’s production of chemical messengers called neurotransmitters out of whack. Like Alzheimer’s, this form of dementia can cause confusion. It also shares some symptoms—tremors, rigid muscles, slowed movement—with Parkinson’s disease.
• Frontal, which attacks the frontal lobes of the brain that govern emotion, social behavior and impulse control. Patients with this sort of dementia may conduct themselves in extremely inappropriate ways. For example, they may make advances towards a caregiver trying to bathe them or suddenly decide to sell a car for $10.
Traumatic brain injury (TBI) has been associated with dementia risk. In one study, older war veterans who suffered TBIs have been found to experience cognition problems at twice the rate of veterans without such injuries (Alzheimer’s Association International Conference, 7/11). Sleep apnea, in which a person stops breathing for short periods of time during the night, may increase the risk of cognitive impairment by 85% among elderly women (JAMA 8/10/11). And calcified buildups in the carotid arteries that feed the brain have been linked to both dementia and stroke.
Stalling for Time
A cure for dementia remains elusive and mental abilities, once lost, are generally lost for good. However, delaying symptoms through lifestyle changes can confer huge benefits, experts say. A delay of a year or two—or of even a few months—will not only save
billions in healthcare costs but will also help alleviate suffering and disruption for millions of families. Researchers
at the Alzheimer’s Association’s International Conference this past July estimated that a 25% reduction in risk factors such as obesity and smoking could prevent up to 500,000 Alzheimer’s cases in the US and 3 million worldwide.
With this goal in mind, the National Institute of Aging has launched a Prevent Alzheimer’s by 2020 campaign (www.pad2020.org). California’s Orange County has recruited 1,000 citizens and 100 doctors to participate in its Alzheimer’s education and prevention program, Vital Aging
(www.ocvitalaging.org/home.seam), the first of its kind in the country. In addition, doctors around the country are opening brain health clinics to help patients stave off cognition problems.
“By exercising and maintaining your weight, you can get up to 100% delay,” says William Shankle, MD, of the Hoag Neurosciences Institute in Irvine, who is directing the Orange County effort. “So if the average duration of mild dementia is two years, with these steps, it becomes four years.”
Recently, several controlled, double-blind studies have began to prove that a healthy diet, intellectual stimulation and exercise can not only increase brain size but also improve brain
function. This research has provided “the first solid evidence that certain interventions can be effective in promoting brain health,” says Majid Fotuhi, MD, PhD, founder of the Neurology Institute for Brain Health and Fitness in Baltimore.
A study published in the Proceedings of the National Academy of Sciences followed two groups of patients: One group just stretched, the other walked for 45 minutes three times a week. After a year, researchers found that those who walked had a measurable increase in the size of the hippocampus, the brain’s traffic cop, the structure that coordinates other brain functions and plays a key role in memory formation. The walkers also did better on memory tests.
The fact that simply going for regular walks should reassure people who believe exercise has to be exhaustive to be helpful. “You don’t have to go to extremes,” says Gary Kennedy, MD, director of geriatric psychiatry at Montefiore Medical Center in New York City. “It’s good common sense.”
One of the big advances in neurology over the last decade or so is the growing understanding that the brain is not static—that people can strengthen different mental abilities throughout life.
But, as with moving one’s muscles, brain exercise a “use it or lose it” proposition. Watching TV for more than two hours a day has been found to increase your risk of memory problems. In contrast, studies over the past decade show that learning new skills, such as a language or a musical instrument, can reduce rates of cognitive decline by 30% to 60%.
In one study, participants who performed a complex balancing task for only two sessions experienced an increase in the frontal areas of their brains (Journal of Neuroscience 9/10). In another investigation, German researchers followed medical students and physical therapy students as they prepared for their national board exams. The medical students, who had to master more information, experienced measurable increases in the size of their hippocampus.
“We need to stop thinking about Alzheimer’s and dementia as a late-life problem,” explains Paul Nussbaum, PhD, chairman of the Alzheimer’s Foundation of America’s Prevention Advisory Board and assistant professor at the University of Pittsburgh School of Medicine. “Clinical symptoms may begin at a certain age, usually after 65. That’s not the same thing as when the disease begins, which may be many years before, if not a lifelong process, of protein breakdown in the brain.”
Reducing Your Risk
Every major chronic disease—particularly heart disease, high blood pressure, high cholesterol, obesity, diabetes, cancer and depression—is associated with an increased risk of cognitive problems. For example, nearly 18% of the dementia cases in one study were attributed to having a pre-hypertensive blood pressure of between 120 and 140 mm Hg (Hypertension 6/10).
This makes going for regular check-ups and managing any problems that do arise crucial to maintaining brain health. Ignoring early symptoms may lead to permanent loss of ability, researchers caution.
In addition to regular exercise, eating a healthy diet can help maintain cognition and memory. According to a study in the March 2011 American Journal of Clinical Nutrition, following a Mediterranean diet plan—based primarily on produce, extra-virgin olive oil, whole grains, unsalted nuts and fish—leads to a slower rate of cognitive decline.
“A good rule of thumb is that if it’s good for your heart, it’s probably good for your brain,” Nussbaum says.
Specific nutrients may help you keep your mind sharp over time. Several studies show that eating foods high in vitamins C and E reduces the risk of memory problems. And a review in Nature found that DHA (a type of omega-3 fatty acid) may help prevent cognitive decline.
In addition, middle-aged folks should make an effort to get a good night’s sleep. A 2009 study led by
Washington University researchers showed that levels of amyloid rise during wakefulness and fall during sleep. Though it has not yet been proven that sleep deprivation causes brain function to falter, there have been enough observation studies to merit a better-safe-than-sorry approach to getting enough shuteye as one goes through one’s middle years.
Stress relief helps, too. A 2011 study in mice also showed that stressful life events and chronic stress can lead to a spike in a chemical that modulates amyloid production. While more research needs to be done, these preliminary results have led researchers to theorize that a lifetime of stress may cause a cascade of chemical changes that leads to Alzheimer’s disease.
There is still a lot of work to be done. Researchers say they have yet to pinpoint the definitive causes of dementia or to devise a treatment that can truly reverse decline once it has begun. But the general path is clear. “We’ve got enough research to get started with prevention,” says Nussbaum. “We need to get moving and make changes based on this research.”
Why Is Dad Doing That?:
Ten Unwanted Behaviors Alzheimer’s Patients Exhibit…
and How to Deal with Them
While every case of Alzheimer’s disease and dementia is different, Nataly Rubinstein, MSW, LCSW, C-ASWCM, author of the new book Alzheimer’s Disease and Other Dementias: The Caregiver’s Complete Survival Guide (Two Harbors Press, www.AlzheimersCareConsultants.com), says there are practical ways for caregivers to successfully deal with the behavioral changes that result from a patient’s memory loss. Here are ten “problem” behaviors that caregivers often have to deal with—and ways that Rubinstein recommends you can best respond to these changes if they crop up in your relationship with your loved one:
1) PROBLEM: Compulsive Behaviors (Dad keeps taking everything out of his wallet and putting it back in.) Your loved one with Alzheimer’s may constantly check to see if the door is locked, empty or rearrange wallets or purses, pack and repack clothing, etc. These things are all manifestations of anxiety. The patient knows he has something important to remember but has forgotten what it was...and this causes his repetitive behaviors. The “big four in anxiety” are the basics for all of us: food, shelter, clothing, and family, and it’s not surprising that many compulsive behaviors revolve around these issues. (A man’s wallet signals to him that he is still a provider, for instance, so he may seem obsessed with going through its contents.)
SOLUTIONS: First, ignore the behavior and remember that although it seems strange to you, it’s probably not doing any real harm. Giving cease-and-desist advice to your loved one will only spark stress and arguments. Plus, if a behavior isn’t reinforced, it may stop. In general, do all you can to help the patient cope with his anxiety. Speak in a calm, gentle voice, and don’t be afraid to touch or hug. Remember, the person is seeking reassurance. Your job is to show him that he is safe, loved, and respected.
2) PROBLEM: Repeating (My wife asks me the same question over and over again, even though I answered it—yet again—not five minutes ago.) At their cores, Alzheimer’s and dementia are diseases of forgetting. As these illnesses progress, patients live increasingly “in the moment,” and they lose the ability to think and process information. For someone in this situation, repetition—whether it’s asking a question, stating a fact, or telling a story—is comforting.
SOLUTIONS: It will take patience on your part, but it’s usually best for everyone if you answer the same question or listen to the same story again and again. Handling repetitiveness in this manner doesn’t hurt you, it helps your loved one, and it can prevent much more serious episodes of agitation, confusion, or aggression. Also, when dealing with an Alzheimer’s or dementia patient, it’s always best to keep your conversation as simple and direct as possible in order to avoid miscommunications that might spark confusion and repetitive questions.
3) PROBLEM: Toileting Problems (Dad has started peeing on the couch, in the bathtub, and even out in the yard!) It’s common for Alzheimer’s patients to struggle with incontinence. Sometimes they simply don’t realize they need to use the bathroom or can’t make it there in time. And other times, they may have forgotten the location of the bathroom or what its purpose is. Nobody has accidents on purpose, and patients will often offer alternative explanations as to why, for instance, the bed or couch is wet—such as spilled drinks or leaky roofs.
SOLUTIONS: Right off the bat, realize that it’s okay to feel extremely reluctant to take on this particular cleaning task. When an adult can no longer control his bladder or bowels, it’s natural for caregivers to feel distressed. If you’re experiencing toileting problems, the first step is to make a doctor’s appointment to ensure that another medical condition or medication isn’t the cause. Establish a regular bathroom routine and encourage the patient to go instead of asking whether or not he needs to.
You may also find it helpful to place signs indicating where the bathroom is, make the toilet seat a different color, provide clothes without complicated zippers or buttons, or buy pads for beds, furniture, and cars. Ultimately, don’t beat yourself up if you feel too overwhelmed by toileting problems. It might be better for all involved to call in outside help rather than force yourself to face changing a parent’s diaper.
4) PROBLEM: Refusal to Bathe (Mom insists that she took a shower this morning, but I know she hasn’t bathed in several days.) An Alzheimer’s or dementia patient who once paid scrupulous attention to her grooming and beauty rituals may gradually begin to “let herself go.” In the beginning, you may not notice small changes, but it’s impossible to ignore when someone to whom you’re close wears the same clothes for days at a time or hasn’t cleaned herself in awhile. Some patients actually believe that they have bathed recently; others may have forgotten the steps it takes to clean oneself, think that there’s no need to bathe if they haven’t perspired, be afraid of water or showers, or not want to ruin a hairdo. No matter the reason (even if it is somewhat logical), refusal to bathe is a major issue for those who live in close proximity with the patient.
SOLUTIONS: Know that forcing someone to bathe when she doesn’t want to isn’t an easy or one-size-fits-all task—and also acknowledge that you aren’t being unreasonable in insisting that this happen. Your own physical and emotional well-being are in play here, too. If appropriate, try to reason with your loved one by telling her that you’ll have visitors or must go to a doctor’s appointment and that you know she’ll want to look her best. Also, you can make showering easier by pre-measuring shampoo, setting water and room temperatures to the patient’s desired level, playing music, etc. Above all, keep in mind that a person with memory problems needs to feel safe and secure, so do everything possible to prevent her from feeling threatened or humiliated in this intimate setting.
5) PROBLEM: Wandering (My husband walked out the door and was halfway down the street before I noticed!) When people wander—whether they’re experiencing memory loss or not—it’s usually because they’re looking for a safe or comfortable place. Your loved one might be seeking a bathroom, a person or place from his past, or relief from boredom or pain. (Or he may have simply become confused while getting the mail.) When they’re seeking something in particular, Alzheimer’s and dementia patients can be very adept at slipping away—even if they’re wheelchair bound!
SOLUTIONS: Wandering is a behavior change that is imperative to address, because becoming lost or being unaware of surroundings can have dire consequences for those suffering from memory loss. Whether your loved one has a history of wandering or not, buy him a Safe Return necklace or bracelet through the Alzheimer’s Association. You might also change locks, install a security system in the patient’s home, or make use of baby gates. Again, making your loved one feel secure is paramount, so don’t call attention to any changes you may make in the living environment. And pay special attention to making sure that he doesn’t wander away during outings.
6) PROBLEM: Paranoia (My mother thinks that I’m trying to poison her.) Paranoia boils down to fear. And people who are suffering from memory loss have a lot to be afraid of. As time goes on, Alzheimer’s patients lose the ability to recognize their homes, their friends, their family, and even their own reflections in the mirror. In the midst of this unfamiliarity, they’ll struggle to make some sense of their situations, and they can hold on to the ideas they form for quite some time. Even though your loved one’s belief that you’re trying to steal her jewelry may seem irrational to you, it’s nothing short of reality to her. (In this situation, you may have asked to borrow a certain necklace years ago. Mom can’t find it now, so—clearly—you must have taken it!)
SOLUTIONS: Dealing with paranoia is tricky. The best things you can do are to remember that your loved one isn’t trying to hurt you, and to try not to take things personally. Know beforehand that rational explanations and clarifications probably won’t work, so don’t pin your hopes of returning to “normal” on them. And while there may be nothing you can do to help the patient return to reality, it’s always a good idea to schedule medical appointments to check for other illnesses, sensory deficits, or side effects from medications.
7) PROBLEM: Hallucinations (My father keeps talking to someone who isn’t there.) Hallucinations are closely related to paranoia. A hallucination is a misperception of reality, often sparked by changes in the brain that cause the patient to see, hear, feel, or smell something that no one else does. Rubinstein recalls a client, Max, who loved his cat, Morris. Max enjoyed playing with Morris, grooming him, and watching TV with him. The only problem was, Morris didn’t exist…and Max’s hallucination was driving his wife, Alice, over the edge!
SOLUTIONS: In the case of Max and Morris, Rubinstein advised Alice to change her attitude about the imaginary cat. Instead of letting Morris upset her, Alice realized that the cat wasn’t hurting anyone and was making Max happy—plus, he was the perfect pet since he didn’t shed, make noise, or make a mess. Like Alice, if your loved one’s hallucinations aren’t doing any harm, do your best to live with them and not allow them to become a bone of contention. Keep in mind, too, that changes in environment or medication can trigger hallucinations. If your loved one is hallucinating (or experiencing paranoia, for that matter), warn visitors in advance so that they don’t inadvertently exacerbate the situation.
8) PROBLEM: Sundowning (My wife gets agitated and starts trying to find her own mother every day in the late afternoon.) Many Alzheimer’s and dementia patients perceive their environments differently as the light begins to fade toward sundown—and this sensory confusion can cause them to become anxious, paranoid, or aggressive. Understandably, sundowning is frightening for the person whose world seems to be becoming more menacing by the minute. In her eyes, the light pole outside the living room might become a threatening intruder, and she will begin to look for a safe place.
SOLUTIONS: First, realize that once sundowning begins, the most you can do is provide a secure place for the patient and tell yourself that tomorrow is another day. As is the case with paranoia, there’s very little you can do to convince your loved one that the reality she’s experiencing isn’t accurate once she has worked herself into an agitated state. However, you can take steps to decrease or avert sundowning’s effects. Stick closely to a daily routine, and start turning on lights mid-afternoon. You can also encourage your loved one to be as active as possible during the day (and thus tired toward evening) and to sit in the sunlight for at least 20 minutes to reset circadian rhythms.
9) PROBLEM: Aggression and Violence (My once-loving husband is increasingly nasty to me when I talk to him and try to help him complete tasks.) For individuals suffering from a form of memory loss, many actions, requests, and events can trigger a volcanic moment (one that you probably didn’t see coming). Since Alzheimer’s and dementia cause the brain’s pathways to work differently, communication doesn’t “work” the way it used to. Things that seem normal to the caregiver (like getting out of bed after a nap, needing to bathe, or eating a meal) may seem threatening to the patient, thus sparking belligerence, arguments, or even combativeness. Plus, since politeness is a learned behavior, it (along with other social mechanisms) can be stripped away by memory loss.
SOLUTIONS: As with paranoia, try not to take aggression personally. People suffering from dementia are often frightened and in survival mode, and they lack other outlets for relieving stress. Of course, it’s always a good idea to consult a doctor and check to make sure that the correct medications are being taken. However, an educated caregiver is often the best medicine of all for patients who are aggressive. Your behavior can either fuel the fire or help extinguish the flames. It’s important to remain calm and reassuring, and to approach reality as your loved one sees it. (In other words, trying to reason probably won’t have a positive effect.) If you feel that you’re in danger or can’t handle the situation, though, leave the room, get to a phone, and call for support.
10) PROBLEM: Sleep Problems (Mom wakes up frequently at night, and as a result we’re both tired and cranky all day.) As we age—whether we’re suffering from Alzheimer’s or not—the quality of our sleep tends to change. Individuals can wake up frequently due to the need to go to the bathroom, pain, anxiety, restless leg syndrome, or even a confusing environment. And when you’re a caregiver, your loved one’s sleep problems become your sleep problems. Obviously, consistent sleep deprivation won’t help either of you to function or cope well. On the other hand, it’s also possible for patients to sleep too much.
SOLUTIONS: First, make sure that your loved one is physically comfortable in terms of her clothing, temperature, lighting, mattress, pillows, etc. Helping her to be mentally comfortable so that she can rest well might be a bit trickier. Try to minimize stress around the clock, stick to a routine, and provide reassurance rather than giving orders. For instance, you might tell your mom that you know everyone in the house is safe at night because she’s so careful about checking the doors instead of suggesting she go to bed because she’s already checked the locks twelve times. If your loved one sleeps too much, limit daytime naps and try to get outside so that the sun can influence circadian rhythms. If your initial efforts don’t work well enough, consider hiring a nighttime aide to give yourself a break.
“Ultimately, while you can’t change the progression of the disease from which your loved one is suffering—or even greatly influence his or her behaviors—you can take steps to minimize the stress both of you feel as a result of behavior changes,” says Rubinstein. “Remember that educating yourself is one of the smartest things you can do—and never be afraid to ask for help and support if you feel that you’re having trouble handling things yourself.
“Also, keep in mind that while many of the behaviors that result from memory loss can be difficult to deal with, it doesn’t mean all the joy is gone from your life and that of the patient,” she adds. “Caring for my mother wasn’t always easy or enjoyable, but I can assure you that we did share plenty of smiles, laughs, and yes, love. You, too, can have a positive impact on the patient’s quality of life—and you can definitely still enjoy special moments with your loved one.”