I’m sure by now you will have appreciated that one of the key messages I try to deliver is that lifestyle changes can drastically move the needle on the risk of developing a wide range of diseases, and maximise the chances of living healthily for as long as possible. You may also think I’m a bit nerdy in my own life about living it in such a way that I ‘practice what I preach’!
I have previously written about the concept of ‘what is your why?’ I encourage readers and patients to really delve into this question. Why do we do the things we do? I won’t go over old ground in my own case, but I will offer an update.
I have never written about this before, but it is highly relevant here. Very sadly my mum has dementia. She isn’t old (late 70s at the time of writing), and has enjoyed pretty good health up until recently. The progression over the last year or two has been alarming, and she would now be unable to manage a 24 hour period without assistance. I strongly believe that optimising my own lifestyle choices will help to minimise my own risk of developing this awful disease.
Dementia and other neuro-degenerative diseases are a huge issue, to put it mildly, and they are only going to become more prominent. Having watched the decline of my mum, I can honestly say that I would rather get pretty much anything else than dementia. The impact it has on patients and their families is profound. It is something we should all be thinking about, as will likely touch all of us in one way or another given how common it is becoming. There are nearly 1 million people in the UK with it, and 1 in 3 will develop it in their lifetime.
Many of the principles are shared with other long term conditions, such as heart disease, another reason it is relevant for my blog! Brain health is probably not something many people think about often. I hope to convince you we should change that, because our own individual risk is not set in stone.
What is dementia?
There are a number of what are known as neuro-degenerative diseases (Alzheimers, Lewy-Body for example), and it is beyond the scope of this blog to outline the specific differences. Dementia itself it a catch-all term for the inability to remember, think or make decisions in day-to-day life. The conditions often take many years or decades to develop. Some are associated with movement disorders, others less so.
Why does dementia occur?
‘Senility’ was recognised long ago by the ancient Greeks, but it wasn’t until the 1960s that it was recognised that dementia was a disease rather than just part of ageing. Alois Alzheimer was a psychiatrist who worked in the state asylum in Frankfurt, Germany, in the early 1900s. He noticed on the post mortem of a patient who had symptoms of what we would now recognise as dementia, that her brain had a strange white substance entangled in her neurons. It took nearly a century for these tangles to be known as ‘Tau’. You may not have heard of Tau, but many have heard of amyloid? Amyloid is a protein that can become mis-folded, and prompt the collection of Tau in brain connections. More on this in a future post.
Genetics
Dementia appears more common in some families than others, but the genetics are complex. The commonest gene we look for is APOE (not to be confused with Apo A and B that I have written about before with respect to cholesterol and heart attack risk, although there are some similarities!). We each get two copies of the APOE gene, one from each parent. If you are unlucky enough to inherit a bad version of this from both parents, the risk of getting dementia is about 12x. Thankfully only about 2% of the population have this genotype.
Treatment
I’m conscious that this all appears rather doom and gloom, but thankfully, it is not a death sentence – the risk is modifiable.
For over a decade, scientists have thought that if amyloid protein is the primary problem in dementia, the key to treatment must be drugs which reduce its production or stimulate its clearance from the brain. Initial efforts however, whilst they reduced the amount of protein, did little to improve clinical symptoms and outcomes.
Studies are ongoing to determine whether giving drugs very early in the condition (in people for example with evidence of amyloid in their brains but no symptoms of dementia) can halt or even prevent it. Let’s hope they yield positive results.
However, what if amyloid isn’t in fact causing the problem, but is simply associated with it? Cause and association are not the same thing, as I mention regularly when describing clinical trials. Around 25% of patients with amyloid in their brains at post mortem have no evidence of dementia when alive. In addition, around a third of patients with overt dementia have no evidence of amyloid on brain scans. This scenario is common in medicine. Biology is often not black and white, and this speaks to the importance of communicating information to patients in a way they can understand and interpret themselves.
Alternative hypotheses
In the 1990s, partly in response to conflicting evidence for amyloid, the theory emerged that blood supply to the brain was an important point that had until that point been overlooked. Stroke victims, who either have a bleed on the brain or an embolism are more likely to suffer dementia. Patients with diabetes have a 2-3x risk of developing dementia. Patients with metabolic syndrome are at increased risk. In the same way that a lack of blood and oxygen can cause a heart attack, might these factors affect the brain over many years?
The term now in common use is vascular dementia, and this makes up around one fifth of cases in Europe.
Inflammation also appears to play a role. In much the same way as cancer, and other chronic issues like heart failure, dementia patients have higher levels of inflammatory markers in their blood than controls. Might targeting inflammation therefore also play a role?
Gender differences
Alzheimers is nearly twice as common in women as in men. Women on average live longer, but this alone shouldn’t explain it. There is a school of thought that the menopause is a factor, but also how many children a woman has had, when she started menstruating, and oral contraceptive use may influence the risk.
On the flip side, Lewy body dementia and Parkinsons disease, which are related neuro-degenerative diseases, and twice as common in men as in women. Again, the exact reasons are unclear.
So whilst we wait to better treatments to be developed, what can the likes of you and I do?
Prevention
A question I have asked myself many times is can dementia be prevented? Billions are spent looking for treatments, and hopefully success will come, but what if there were ways we could reduce our risk in the first place?
Primary prevention is the term doctors use for interventions designed to reduce the risk of a condition developing before there are any signs of it. I consider myself an ‘at risk’ adult (remember statistically one third of us could be affected to a degree), even though at the time of writing I am 45 years old. Dementia, much like heart disease, is many decades in the making. Lifestyle choices I make consistently at this point in my life are statistically likely to reduce my risk of a number of chronic health issues in my 70s, 80s, and perhaps beyond. An argument in support of this, is that the clear signs of dementia actually occur fairly late. So-called ‘pre-clinical stage’ changes in the brain can occur for decades before the onset of symptoms, but a patient may still have very subtle features of mild cognitive impairment.
Let’s break things down into a few key areas (I will expand on some below):
1. How can we reduce neuropathological damage (whether from amyloid / Tau / vascular / inflammatory causes) ?
- Minimise diabetes
- Treat high blood pressure
A blood pressure >140mmHg at age 55 is associated with a 60% increased chance of dementia over an 18 year period! A recent large study has shown that treating blood pressure to a target of 120mmHg instead of 140 REDUCES dementia risk by 20%.
When did you last get your blood pressure checked? Please, if you haven’t done it in the last few months, get it checked. If you don’t have a machine, your GP or pharmacist will. Patients are often surprised when I quote how low I would like their blood pressure to be, but I hope to have convinced you of its importance.
- Prevent head injury
- Stop smoking – increases the risk of dementia by 60%
- Reduce air pollution
- Reduce mid-life obesity
2. How can we increase and maintain cognitive reserve (brain power)?
A number of studies have looked at this, and the results all point in one direction. Activities such as reading, speaking a second language, playing games, art, playing music…. All of these help.
In people >65, they can reduce the odds of dementia by up to 30% (good news for my mother in law who loves a game of cards with my children!). I would add that I personally think that the idea that people have to retire at a given age is far too simplistic. Why are we marginalising older people who will often have so much to give in the workplace? I do think that their roles may change; for example in my work I can’t see me still operating and putting pacemakers in my 60s, but I absolutely think as an elder medic I would have many supporting roles to play in our hospital. Mentoring roles for older people can absolutely help to keep the grey matter healthy.
- Treat hearing impairment
Hearing loss is surprisingly common, affecting one third of people aged 45-65, yet increases the relative risk of dementia in this age bracket by 90%! It saddens me to say this, but my mum has clearly had hearing impairment for some years, but despite some pressure from myself and others has resolutely refused to address it. I can’t help but wonder if this has contributed to her dementia? Take home message – get your hearing checked (even I have had this done to be on the safe side!)
- Maintain frequent social contact
Loneliness has been identified by the American Surgeon General as a crisis. Covid really didn’t help, but there are many more factors at play here. I am incredibly concerned about the impact of social media on children’s mental health. Although presented by social media companies as a way to connect people, the reality for many, particularly children, is that it can lead to social isolation. Of course it does have many uses, but I for one am glad it did not exist when I was growing up. I also worry about social isolation at the opposite end of the age spectrum, and so have set up a monthly direct debit to a local older person’s charity who do good work in this space.
- Attain high level of education
This is particularly important up to the age of 20 it appears, by which time much of the brain connections are made.
There are also factors that have benefit in both of the camps above, both reducing brain damage, and increasing brain power:
- Maintain frequent exercise
I know I am like a stuck record, but exercise really is a wonder-drug. In patients who are used to exercise, and therefore ‘good’ at moving their bodies, the risk and progression of Parkinson’s disease (which predominantly affects movement) is less. It fact, exercise training actually delays the progression of the condition in affected patients!
If you are 30-60, and break into a sweat (by exercise, not reading the news or in the sun!) once a week, on average you reduce your dementia risk by 20% over the next 25 years. Ask yourself, when was the last time you sweated through physical exertion?
- Reduce depression
Alongside hearing loss, this is actually the highest risk factor, with 90% increased risk. Around 1 in 10 people over the age of 65 have a diagnosis of depression, and this is only getting worse over time.
- Avoid excessive alcohol
Regular consumption of >21 units per week increases the risk of dementia by 20%.
- Sleep – I have covered this before!
- Nutrition
There does appear to be benefit from a Mediterranean diet, but whether this is from reducing conventional cardiovascular risk is less clear. I would always promote a whole food diet, rich in vegetables, whole grains, legumes, fruit and nuts, low in saturated fat and meat. It does not appear from the research that supplementation with vitamins makes any difference however.
You will notice that many of these factors are linked: the person who exercises and doesn’t smoke is less likely to have diabetes, high blood pressure and depression for example. The person who attends an art class once a week is less likely to be lonely or have depression. I have tried to highlight what to me felt like important statistics, and hopefully encourage you to reflect and see what you might do in your own lives, or encourage in the lives of your loved ones.