Category Archives: Dementia

August 27, 2019 · 1:46 AM

Anti-Alzheimers Drugs Are a Waste of Money

dementia, memory loss, Mediterranean diet, low-carb diet, glycemic index, dementia memory loss

“Honey, let’s talk to doc about stopping those drugs.”

I commonly admit patients to the hospital who happen to be taking either Aricept or memantine (or both) in an effort to slow the cognitive decline of dementia. Aricept is a cholinesterase inhibitor, abbreviated ChEI below.

A meta-analysis published in November 2018 in JAMA Network suggests that folks taking those drugs have a more rapid cognitive decline compared to those who don’t. Moreover, the rate of decline for those taking memantine, with or without ChEIs, was faster than those receiving ChEIs only or receiving neither medication.

A typical dose of Aricept (donepezil) is 10 mg/day. The average wholesale price for that pill is $20.23 (USD). One brand of memantine is called Namenda, and the usual dose is 10 mg twice daily. Average wholesale dose for that is $17.80/day.  Take both those drugs daily for one month and it’s $1,140.90. Or $13,690.80 for a year. And that’s the wholesale price.

I can think of a few better uses of that money.

Admittedly, there must be individual patients that respond better than average to these drug, and some respond worse than average. You can’t tell in advance who those are.

Click the link below for the full study. From the Abstract:

Results

Across 10 studies, of 2714 participants, the mean (SD) age was 75.0 (8.2) years, 58% were female, and 9% were racial/ethnic minorities. There were 906 participants (33.4%) receiving ChEIs, 143 (5.3%) receiving memantine, 923 (34.0%) receiving both, and 742 (27.3%) receiving neither. Meta-analysis showed those receiving ChEIs or memantine were associated with significantly greater annual rate of decline on the ADAS-cog [a test of cognition] than those receiving neither medication (1.4 points/y; 95% CI, 0.1-2.7).

Conclusions and Relevance

Similar to observational studies, many participants in AD clinical trials receiving ChEIs or memantine experience greater cognitive decline. This difference is nearly as large as the hypothesized effect sizes of the treatments investigated in the trials. Concomitant use of ChEIs or memantine may be confounded with outcomes on the ADAS-cog and should be considered in design of clinical trials of potential therapeutic agents for AD. Post hoc analyses stratifying by ChEIs or memantine must be interpreted cautiously given the potential for confounding.

Source: Association of Concomitant Use of Cholinesterase Inhibitors or Memantine With Cognitive Decline in Alzheimer Clinical Trials: A Meta-analysis | Dementia and Cognitive Impairment | JAMA Network Open | JAMA Network

Steve Parker, M.D.

PS: The Mediterranean diet helps prevent or postpone dementia.

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August 18, 2019 · 4:50 PM

What’s the Best Blood Pressure Goal If You Have Hypertension?

Not bad

I’m not formally questioning the guidelines of established authoritative bodies, but just maybe they’re too high. The 2017 guideline from the American College of Cardiology recommended a treatment goal of under 130/80. Reduction of cognitive impairment is only one of many considerations in setting a treatment goal.

Aiming for systolic blood pressure of 120 or less (instead of 140) may reduce the risk of age-related brain impairment. A recent study suggests the mechanism is better brain blood flow.

Ischemia means poor or no blood flow.

Small vessel ischemic disease (SVID in the brain) is something I see so often in 70-year-olds that I usually ignore it. Mind you, I’m a hospitalist and usually looking for acute major strokes, brain tumors, and bleeding on CT scans. SVID is a chronic disease and it’s often difficult to say how long a specific lesion has been present and whether it’s causing symptoms. Ischemia in the brain is linked to impaired cognitive functioning and dementia. On the other hand, some brain ischemic lesions don’t seem to cause any detectable impairment.

From JAMA Network:

Question:  Is intensive blood pressure treatment associated with less progression of small vessel ischemic disease, as reflected by cerebral white matter lesion volume?

Findings:  In this substudy of a randomized clinical trial of 449 hypertensive patients with longitudinal brain magnetic resonance imaging, intensive blood pressure management to a target of less than 120 mm Hg, vs less than 140 mm Hg, was associated with a smaller increase in white matter lesion volume (0.92 cm3 vs 1.45 cm3).

Meaning:  More intensive blood pressure management was associated with less progression of cerebral small vessel ischemic disease, although the difference was small.

Source: Association of Intensive vs Standard Blood Pressure Control With Cerebral White Matter Lesions | Dementia and Cognitive Impairment | JAMA | JAMA Network

Steve Parker, M.D.

PS: The Mediterranean diet also reduces dementia and cognitive impairment.

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July 23, 2019 · 2:52 PM

Lowering Blood Pressure to 120 Systolic May Reduce Age-Related Memory Loss, Even Dementia

Exercise also seems to protect against memory loss and dementia

Keep your eyes on this development, folks. Potential game-changer. And a boon to Big Pharma. From NBCnews.com…

Lowering blood pressure to recommended levels can prevent dementia and the memory and thinking problems that often show up first [mild cognitive impairment], researchers reported Wednesday.

People whose top blood pressure reading was taken down to 120 were 19 percent less likely to develop mild cognitive impairment, the loss of memory and brain processing power that usually precedes Alzheimer’s, the study found. And they were 15 percent less likely to eventually develop cognitive decline and dementia.

***

It may take a few more years before the study conclusively shows whether the risk of Alzheimer’s was actually reduced because of the lower blood pressure,the researchers said.

It’s the first intervention that has been clearly demonstrated to lower rates of mental decline.

***

The findings come from a large trial of blood pressure called the Systolic Blood Pressure Intervention Trial, or SPRINT.

It has already found that lowering systolic blood pressure — the top number in a blood pressure reading — to 120 or less can prevent stroke, heart attacks, kidney disease and other problems.

Source: Tight blood pressure control can cut memory loss, study finds

Steve Parker, M.D.

PS: The Mediterranean diet also protects against dementia.

low-carb mediterranean diet

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June 7, 2019 · 5:03 PM

Mediterranean Diet Improves Brain Function in Type 2 Diabetes

I don’t know if the study at hand is valid or not. The abstract is poorly written. The study population was Boston Puerto Ricans only, so may not apply to other ethnic groups. I’m not paying $35 to get access to the full article. Diabetes Self-Management has coverage that will be more digestible than the abstract below.

OBJECTIVE To determine associations of a Mediterranean diet score (MeDS) with 2-year change in cognitive function by type 2 diabetes and glycemic control status and contrast it against other diet quality scores.

RESEARCH DESIGN AND METHODS We used data from the longitudinal Boston Puerto Rican Health Study (n = 913; 42.6% with type 2 diabetes at 2 years). Glycemic control at baseline was categorized as uncontrolled (hemoglobin A1c ≥7% [53 mmol/mol]) versus controlled. Two-year change in glycemic control was defined as stable/improved versus poor/declined. We defined MeDS, Healthy Eating Index, Alternate Healthy Eating Index, and Dietary Approaches to Stop Hypertension scores. Adjusted mixed linear models assessed 2-year change in global cognitive function z score, executive and memory function, and nine individual cognitive tests.

RESULTS Higher MeDS, but no other diet quality score, was associated with higher 2-year change in global cognitive function in adults with type 2 diabetes (β ± SE = 0.027 ± 0.011; P = 0.016) but not without (P = 0.80). Similar results were noted for Mini-Mental State Examination, word recognition, digit span, and clock drawing tests. Results remained consistent for individuals under glycemic control at baseline (0.062 ± 0.020; P = 0.004) and stable/improved over 2 years (0.053 ± 0.019; P = 0.007), but not for uncontrolled or poor/declined glycemic control. All diet quality scores were associated with higher 2-year memory function in adults without type 2 diabetes.

CONCLUSIONS Both adhering to a Mediterranean diet and effectively managing type 2 diabetes may support optimal cognitive function. Healthy diets, in general, can help improve memory function among adults without type 2 diabetes.

Source: The Mediterranean Diet and 2-Year Change in Cognitive Function by Status of Type 2 Diabetes and Glycemic Control | Diabetes Care

Steve Parker, M.D.

low-carb mediterranean diet

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November 17, 2017 · 8:33 AM

Brain Benefits of Exercise Diminish After Short Rest, According to Gretchen Reynolds

Run, Spot, Run!

Run, Spot, Run!

Admittedly, Gretchen may not have written the headline to her article at Carlos Slim’s blog. The headline is wrong. The gist is that blood flow to the brain diminishes in older competitive runners if they stop exercising for 10 days. Tests of cognitive function showed no deterioration.

Click the link below to read Gretchen’s article, which is brief. A snippet:

Before you skip another workout, you might think about your brain. A provocative new study finds that some of the benefits of exercise for brain health may evaporate if we take to the couch and stop being active, even just for a week or so.

I have frequently written about how physical activity, especially endurance exercise like running, aids our brains and minds. Studies with animals and people show that working out can lead to the creation of new neurons, blood vessels and synapses and greater overall volume in areas of the brain related to memory and higher-level thinking.

Presumably as a result, people and animals that exercise tend to have sturdier memories and cognitive skills than their sedentary counterparts.

Exercise prompts these changes in large part by increasing blood flow to the brain, many exercise scientists believe. Blood carries fuel and oxygen to brain cells, along with other substances that help to jump-start desirable biochemical processes there, so more blood circulating in the brain is generally a good thing.

Source: Brain Benefits of Exercise Diminish After Short Rest – The New York Times

I believe regular physical activity does help preserve brain function over time. But there’s more involved than blood flow.

Steve Parker, M.D.

PS: I bet your brain blood flow increases, compared to watching Dancing With the Stars on Tell-a-Vision, if you read one of my books.

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December 7, 2016 · 10:37 AM

Does Type 2 Diabetes Cause Alzheimer’s Dementia?

dementia, memory loss, Mediterranean diet, low-carb diet, glycemic index, dementia memory loss

“More basic research is critical.”

Several scientific studies, but not all, link type 2 diabetes with Alzheimer’s disease. Some go so far as to say Alzheimer’s is type 3 diabetes.

My Twitter feed brought to my attention a scientific article I thought would clarify the relationships between diabetes, carbohydrate consumption, and Alzheimer’s dementia (full text).

It didn’t.

Click the full text link to read all about insulin, amylin, insulin degrading enzyme, amyloid–β, and other factors that might explain the relationship between type 2 diabetes and Alzheimer’s dementia. You’ll also find a comprehensive annotated list of the scientific studies investigating the link between diabetes and Alzheimer’s.

Bottom line: We still don’t know the fundamental cause of Alzheimer’s disease. A cure and highly effective preventive measures are far in the future.

Action Plan For You

You may be able to reduce your risk of Alzheimer’s disease by:

  • avoiding type 2 diabetes
  • preventing progression of prediabetes to diabetes
  • avoiding obesity
  • exercising regularly
  • eating a Mediterranean-style diet

Carbohydrate restriction helps many folks prevent or resolve obesity, prediabetes, and type 2 diabetes.

Steve Parker, M.D.

Reference: Schilling, Melissa. Unraveling Alzheimer’s: Making Sense of the Relationship Between Diabetes and Alzheimer’s Disease. Journal of Alzheimer’s Disease, 51 (2016): 961-977.

LCHF Mediterranean diet

LCHF Mediterranean diet

 

 

 

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November 13, 2016 · 8:00 PM

Seafood Linked to Lower Alzheimer Dementia Risk in Those Genetically Predisposed

…according to an article at the Journal of the American Medical Association. The study involved Chicago-area residents who had provided information about their eating habits. After death, their brains were biopsied, looking for typical pathological findings of Alzheimers Disease.

fresh salmon and lobsters

Rich sources of omega-3 fatty acids include salmon, sardines, herring, trout, and mackerel

Participants who ate seafood at least once a week had fewer Alzheimers lesions in their brains, but only if they were carriers of a particular gene the predisposes to Alzheimers. The gene is called apolipoprotein E or APOE ε4.

You’ve heard that seafood may be contaminated with mercury, right? The seafood eaters in this study indeed had higher brain levels of mercury, but it didn’t cause any visible brain damage.

The Mediterranean diet, relatively rich in seafood, has long been linked to a lower risk of dementia.

A weakness of the study is that the researchers didn’t report results of clinical testing for dementia in these participants before they died. You can have microscopic evidence of Alzheimers disease on a biopsy, yet no clinically diagnosis of dementia.

Steve Parker, M.D.

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October 13, 2016 · 4:17 PM

From P.D. Mangan: Higher Altitude Means Much Lower Death Rates

Adult life is a battle against gravity. Eventually we all lose.

Adult life is a battle against gravity. Eventually we all lose.

I quote:

“Death rates from both of these cancers [breast in women, colon in men] were about half as high at an altitude of greater than 1000 meters (3300 feet).  The study also found about a 30% reduction in deaths from coronary artery disease at >1000 meters.

This accords well with a number of other studies. For example, “Lower Mortality From Coronary Heart Disease and Stroke at Higher Altitudes in Switzerland“. This study found 22% less heart disease death for every +1000 meters in altitude, and 12% less stroke death.

“Association Between Alzheimer Dementia Mortality Rate and Altitude in California Counties“: This study found about half the death rate from Alzheimer’s at an altitude of 1600 meters vs that at sea level.

There’s less diabetes at high altitude.”

Source: Higher Altitude Means Much Lower Death Rates – Rogue Health and Fitness

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Filed under cancer, Causes of Diabetes, Dementia, Heart Disease

July 7, 2015 · 6:48 AM

Preserve Your Hippocampus With Exercise

MRI scan of brain

MRI scan of brain

The NYT’s Well blog has the details. The brain’s hippocampus is a critical center for memory. Alzheimers disease is associated with a gene called apo-E4. Carriers of that gene who exercise regularly have less shrinkage of the hippocampus than non-exercisers.

To PROVE that regular exercise prevents dementia-related shrinkage of the hippocampus, you’d have to force some folks to exercise and stop others who wanted to exercise. A couple years later, scan their brains and compare the two groups. That study may never be done.

The Mediterranean diet also seems to prevent or forestall dementia.

Steve Parker, M.D.

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March 29, 2015 · 4:59 AM

Preserve Your Brain Function Despite Aging

There are ways of slowing or reversing losses in cognitive function. The most effective discovered so far is physical exercise, which protects the brain by protecting the body’s cardiovascular health. Mental exercise, often called brain training, is widely promoted, but it boosts only the particular skill that is practised – its narrow impact mirroring that of educational interventions at other ages. Various drugs are being investigated for their value in staving off normal cognitive decline, but for now preventive maintenance is still the best bet – avoid smoking, drinking to excess, head injuries and the like.

MRI scan of brain

MRI scan of brain

The quote above is from an Instant Expert paper on intelligence. It’s full of interesting facts such as the typical difference in IQ between strangers is 17 points. It answers the question whether an enriched school or home environment can increase intelligence.

Also, for preserving brain function, I think the Mediterranean diet helps, but it’s difficult to prove.

On a different note, the article mentions overload of patients’ brains when medical care is too complicated:

Given the complexity of self-care regimes, it is hardly surprising that some people make dangerous errors or fail to comply. The effective management of diabetes, for example, requires a person to keep blood sugar levels within a healthy range, which means coordinating diet, exercise and medication throughout the day, which in turn requires planning for contingencies, recognising when blood sugar is veering too high or low, knowing how to regain control and conceptualising the imperceptible but cumulative damage caused by failing to maintain control. There is no set recipe for people with diabetes to follow – their bodies and circumstances differ. Moreover, they get little training, virtually no supervision and no days off. Effectively managing your diabetes is a cognitively complex job and poor performance has serious consequences, including emergency room visits, lost limbs or eyesight, and even death. The lower the diabetic person’s IQ, the greater the risks.

You’ll also learn about the Flynn effect and possible explanations for it:

Over the past century, each successive generation has answered more IQ test items correctly than the last, the rise being equivalent to around 3 IQ points per decade in developed nations. This is dubbed the “Flynn effect” after the political scientist James Flynn, who most thoroughly documented it. Are humans getting smarter, and if so, why? 

I’m more inclined to think Idiocracy describes our future.

Steve Parker, M.D.

h/t James Fulford

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