Is It Time to Focus on Preventive Strategies for Alzheimer’s Disease, and Advocacy for Standard, Routine Cognitive Screening?

Despite decades of research, we remain with neither cure nor treatment that modifies Alzheimer’s disease in any significant way.

It is now understood that the changes in the brain that will ultimately produce the progressive, irreversible symptoms of Alzheimer’s disease begin many years before symptoms become apparent and  these changes may be caused by many different factors. This knowledge has prompted investigation into whether early detection of known risk factors can result in proactive strategies to prevent or delay the cognitive and eventual physical declines associated with the disease.

The greatest unmodifiable risk factor for Alzheimer’s disease is age, and the population of the United States is aging. It is estimated that by 2030, 20 percent of Americans will be over the age of sixty-five, the age after which 95 percent of Alzheimer’s cases occur.

It is currently estimated that close to six million Americans have Alzheimer’s disease. This number is predicted to more than double by 2050. We must also be mindful of the number of caregivers attending to these six million patients and the stress and burden they experience, potentially adversely affecting their health and wellbeing.

A disease with no cure or disease-modifying treatment inspires us to consider how to prevent it in the first place or identify it at the earliest possible moment. Thousands of clinical trials have thus far failed in their search for meaningful therapeutics, with many stating failures are at least partly based on participants being too far along in the disease process to be helped by the trial medication. While the search continues, we can now learn and engage in strategies that are proactive and preventive.

“Primary prevention” refers to those lifestyle choices one can make that are believed to protect from disease and disability. Brain-protective lifestyle choices are many, providing opportunities to lessen the risk of developing Alzheimer’s disease or at least delay the disease for many years.

Lifestyle choices empower individuals to make changes and engage in behaviors that not only benefit brain health, but also protect the heart and cardiovascular system. The brain relies heavily on glucose (sugar) and oxygen which are delivered to the brain in blood vessels. Vascular health, then, is vital to brain health. Many of the following lifestyle strategies benefit vascular health, and serve as primary prevention for cognitive impairment, symptoms of dementia, and Alzheimer’s disease.

Heart and Brain Healthy Choices

• Do not smoke – smoking accelerates brain aging, loss of brain volume, and thus increases the risk of developing symptoms of dementia.
• Get adequate sleep – deep and dream sleep (or rapid eye movement -REM) sleep is vital for brain health. In deep and dream sleep states we consolidate new information into long term memory and the brain is able to “clean” itself, flushing out toxins,  including beta-amyloid which may otherwise accumulate and which is a component of the pathology of Alzheimer’s disease. The Centers for Disease Control and Prevention (CDC) has information about the importance of quality sleep and tips for better sleep at:

www.cdc.gov/sleep

• Avoid or control high blood pressure (“hypertension”) – hypertension damages blood vessels, contributing to heart and vascular disease, symptoms of dementia, and Alzheimer’s disease
• Avoid or control Type 2 diabetes – high blood sugar damages nerves and blood vessels, also contributing to cardiovascular disease, symptoms of dementia, and Alzheimer’s disease
• Heart and Brain healthy menu diets – the following diets are all considered beneficial for cardiovascular and brain health. They emphasize foods that are high in fiber (whole grains, fruits, vegetables, seeds, legumes), high in Omega 3 fatty acids (walnuts, salmon, tuna, mackerel, sardines, extra virgin olive oil), leafy green and cruciferous (cabbage family) vegetables (cabbage, broccoli, cauliflower, spinach), berries, and fermented foods (sauerkraut, miso, olives, pickles). Heart and brain healthy diets deemphasize foods that are considered to cause inflammation, such as red meat, saturated fats, refined sugars, pasta, potatoes).

Following are three recommended diets and website for more information:

• Mediterranean mediterraneandiet.com
• DASH (“Dietary Approaches to Stop Hypertension) mydash.diet
• MIND https://www.healthline.com/nutrition/mind-diet

The MIND diet combines concepts of the Mediterranean and DASH diets

• Physical activity – just 2.5 hours per week of physical activity can protect heart and brain! Walking is fine; no need to join a gym or lift heavy weights!
• Challenge yourself to keep learning – reading this article is one such activity! Consider learning a new craft, a new type of brain-teaser puzzle, a new language, a new dance, a period in history you do not know much about – the possibilities are endless!
• Maintain your social contacts – staying socially engaged with friends and family can lengthen your life span, improve your physical health with greater immunity to illness, and even reduce the risks of depression and dementia.
• Protect your head – physical injury to the head can ultimately produce progressive, irreversible neurocognitive decline. Wear your seat belt in cars and wear a helmet when riding a bicycle or motorcycle. Ensure you have assistance when using ladders.
• Maintain optimal dental health – poor dental hygiene or gum disease may put one at higher risk to develop Alzheimer’s disease. Good dental hygiene reduces the chance that one will need invasive dental work during which oral bacteria may get into the blood stream and enter the brain, leading to an immune response that can damage or kill brain cells (neurons) and ultimately lead to symptoms of Alzheimer’s disease.
• Address hearing loss – untreated hearing loss is now recognized as a risk factor for developing Alzheimer’s disease. The mechanism of this relationship may relate to the social isolation that often accompanies hearing loss or changes in the brain structure that occur when auditory input is reduced. There are various types of hearing loss, and many new options for individualized hearing aid approaches.
• Respond to stress in a healthier way – chronic stress can lead to cardiovascular disease, obesity, psychiatric, and the cognitive decline of Alzheimer’s disease. While we cannot always control the stress that comes at us, we are each in control of how we respond!

We can choose situations – and perhaps people – to avoid, we can learn to say “no,” when we are stretched, we can focus on the activity that destresses us: reading, walking, sunbathing, working on crafts or starting a new hobby, keeping a diary, window shopping. We are all unique, and the ways in which we respond to stress in a healthier way will vary as well. Find your way!

• Know your levels of vitamins B12 and D3 – deficiencies in these two vitamins, over time, can increase our risk of cognitive impairment and eventual Alzheimer’s disease.

When we pass age 50, we are not able to process B12 as well from our dietary intake. Those who are vegetarians or vegans may be B12 deficient at any age as their intake of animal products (the source of B12) is minimal or nonexistent. We make vitamin D3 when we are exposed to the sun. Those who stay out of the sun, or wear sunscreen, may not have sufficient levels of this vitamin. Supplements may be needed.

Annual blood work should test for these vitamins, with supplementation recommended if indicated. Primary care providers can recommend the amounts of each vitamin that are appropriate based on the laboratory test results.

• Use your non-dominant hand – we can “exercise” the other half of our brain when we switch hands! Try writing, brushing your teeth and hair, opening doors, using your computer mouse, etc., with your non-dominant hand. You will work the opposite side of your brain that may otherwise be a bit “lazy,” forcing the brain to form new and stronger connections. Yes, we can grow new connections within our brain even as we age!
• Reset your mindset – blocking daily “noise” and stimulation, focusing just on the present, for even a very short period can reduce stress, lower blood pressure, improve sleep, and increase productivity and creativity. According to a variety of published studies, meditation may also enhance cognition and the brain’s ability to adapt over time and recover from insults such as traumatic injury or stroke. This is known as “plasticity,” which was formerly believed to decrease beginning in our twenties but is now believed to be possible throughout life!

For decades, we have embraced primary prevention strategies for dental health, cancers such as cervical, breast, colon, prostate, and lung cancers. Supplementing primary prevention is “secondary prevention,” which refers to screening procedures and tests that can identify a disease in its earliest stage. Our dentists take Xrays and examine teeth and gums. Our primary care provides and specialists order or perform Pap tests for cervical cancer, mammograms and ultrasounds for breast cancer, colonoscopies for colon cancer, blood tests and physical examination for prostate cancer, and chest Xrays for lung cancer. Over the past forty to fifty years, early detection through screening has greatly improved survival rates for these cancers.

It seems that we can apply this same logic to brain health and embrace as many healthy lifestyles as possible and participate in annual cognitive screening to identify the earliest moment that we exhibit impairment.

We should not fear cognitive screening. A screen that shows cognitive impairment does not automatically indicate that the patient has Alzheimer’s disease. At Alzheimer’s Community Care, we have advocated for cognition to be evaluated as a vital sign, the sixth vital sign, accompanying the standard assessments of pulse, blood pressure, temperature, respirations, and pain.

There are common, treatable causes for cognitive impairment. These include:

• Untreated clinical depression
• Underactive thyroid
• Vitamin deficiency, particularly vitamin B12
• Malnutrition/dehydration
• Side effects or interactions of medications
• Low-grade infections: urinary tract, pneumonia, COVID-19
• Untreated or poorly controlled Type 2 diabetes
• Hormone imbalance, such as resulting from menopause
• Brain tumor or lesion
• Chronic pain

Regardless of one’s age, evaluation for these treatable causes should be completed. Although about 95% of Alzheimer’s diagnoses are in the population over age 65, there should be no assumption that the patient has the disease merely based in his/her age. We can remain cognitively intact well into our ninth and tenth decades!

The most recent studies reporting cognitive improvement  or slowing of disease progression involved patients with mild cognitive impairment or early-stage Alzheimer’s disease. Screening provides the opportunity to evaluate for treatable conditions, and for prompt referral to neurology when either treatable causes are not found, or if after treatment, cognition still does not improve. A patient choosing to participate in a clinical trial has a better chance of benefiting from the trial intervention in the earliest stages of the disease.