Postponing Dementia, and …

1. Postponing Dementia, and … LN Matheson, PhD Goaling Institute www.GoalingInstitute.com

2. … Staying Smarter Longer LN Matheson, PhD Goaling Institute www.GoalingInstitute.com

3. Stage Model of Neurorehabilitation

4. What is Dementia? • Dementia is the loss of mental functions, such as thinking, memory, and reasoning, that is severe enough to interfere with a person's daily life. • Symptoms may involve changes in personality, mood, and behavior. • Dementia is not a disease, but a group of symptoms that may accompany certain diseases or conditions.

5. Functional Losses of Dementia • Awareness & Orientation • Attention & Concentration • Memory: Registration & Recall • Receptive and expressive language • Novel problem solving • Judgment • Delirium < 6 months; Dementia > 6 months

6. Alzheimer’s Dementia • “Senile Dementia of the Alzheimer's Type” (SDAT) is responsible for about 50% of the dementias in the United States. • AD is complex, with many risk factors. • AD risk doubles every five years over age 65, with half the 85-year-olds with AD. • We cannot control age and genetic risk factors.

7. Can Alzheimer's Disease Be Prevented? • Early onset AD has clear genetic links, while late-onset AD has several genetic risk factors. • “AD prevention strategies are still in elementary stages of scientific research.” • National Institutes of Health (2006)

8. AD NIH Recommendations (2010) • Independent Panel Finds Insufficient Evidence to Support Preventive Measures for Alzheimer's Disease • "There is currently no evidence of even moderate scientific quality supporting the association of any modifiable factor... with reduced risk of AD... risk reduction for cognitive decline is similarly limited." • "Many preventive measures for... AD.. have been studied over the years... the value of these strategies... hasn't been demonstrated…" • Recommendations made to develop objective measures of cognitive function to measure change over time.

9. AD NIH Recommendations (2011) • New Genetic Risk Factors for Alzheimer's Disease • NIH News April 11, 2011 • "In two massive studies involving thousands of DNA samples, scientists from around the world identified a number of new genes and confirmed several others that may be risk factors for late-onset Alzheimer's disease." • Late onset Alzheimer's disease is the most typical form, appearing after age 60. In addition to the apolipoprotein E. gene variant, five new genes have been identified that are consistently associated with AD.

10. AD & Other Disease Risk Factors • High levels of blood cholesterol is related to both heart disease and AD. • Cholesterol-lowering drugs may postpone AD, but results are equivocal. • Diabetes is associated with AD and other dementias. • The Religious Orders Study; 1,100 since 1993. • Some types of cognitive decline occur with diabetes, but not others.

11. AD Risk Factors, Drugs & Supplements • Homocysteine is associated with increased risk of AD. • Reduced by folic acid, vitamin B6 and B12. • Ibuprofen and naproxen have equivocal results. • Antioxidant dietary supplements have equivocal results. • Vitamin E, and C and selenium are in long-term trials. • Gingko biloba studies continue. • Vitamin E & Aricept: • Vitamin E was not found to be effective; Aricept had modest effect in postponing cognitive decline.

12. AD Risk & Lifestyle Findings • Chicago Health and Aging Project • Cognitive decline appears to be postponed with higher levels of social engagement. • Religious Orders Study • Participation in cognitive activities > lower apparent AD • Formal education appears to postpone dementia in the face of increasing levels of disease. • Cognitive Reserve Capacity • Retirement from (engaging) work an AD risk factor. • Flynn Effect (per LNM): Cohort change 2° < challenge

13. AD Lifestyle Interventions • Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) • Effectively improved cognitive function for elderly people and people with mild AD, up to two years later. • Regular physical activity is significant preventive factor, confirmed by both MRI studies of brain activity and tests of cognitive function.

14. Separate Disease from Dysfunction • Dementia is not a disease; it is the functional expression of a disease process, with age as the primary “risk factor”. • This is a crucial difference. • Postponing functional decline is our focus. • We will return to Functional Aging later.

15. Differentiate Dementia from Disease • Dementingcausesbegin many years before the onset of dementia. • If we treat dementia like heart disease… • … we do what we can to prevent disease, and… • …we also take steps to maintain our fitness.

16. How Many Dementias? • ≈ 50 different causes, often co-morbid. • Degeneration - Alzheimer's, Parkinson's and Huntington's. • Blood vessel diseases > stroke or cerebral ischemia. • Toxic reactions, like excessive alcohol or drug use. • Vitamin B12 and folate deficiency. • Infections; AIDS and Creutzfeldt-Jakob disease. • A single severe head injury or many smaller injuries. • Illnesses of heart, kidneys, liver, and lungs. • ≈ 10% - 20% of causes are treatable.

17. Methods to Detect DementingCauses • Morphologic Changes • CT Scan • Magnetic Resonance Imaging (MRI) • Metabolic Changes • Functional Magnetic Resonance Imaging (fMRI) • Single-Photon Emission Computed Tomography (SPECT) • PET (Positron Emission Tomography) Scans • Florbetapir F18 PET for Amyloid Plaque

18. PET + MRI Scan

19. Dementing-Cause Co-Morbidities • Sustained Grief > Hopelessness > Depression • Unabated Stress > Locked-In Anxiety • Poly-Medication & Self-Medication • Nutritional Imbalances & Type II Diabetes • Insomnia • Psychosis (often delusions of persecution) • Agitation / Aggression > loneliness & inactivity • All of these are treatable. • Left unatttended, they leverage dementing causes.

20. DementingCauses Intervention • Awareness / Education • Prevention = Risk Factor Control • Dietary Prophylaxis of Disease (Increases and Restrictions) • Exercise • Allostatic Load • Treatment of symptoms • Rehabilitation of dysfunction • Improve function • Accommodate dysfunction

21. Dietary Prophylaxis Increases • Blueberries • Pomegranate fruit & juice • Citrus fruits & colorful vegetables • Nuts & Seeds • Walnuts, almonds, cashews, peanuts, sunflower, sesame, flax • Fresh brewed tea • Dark chocolate • Whole grains and brown rice > vascular health • Avocados • Wild salmon, tuna, and herring

22. Dietary Prophylaxis Restrictions • Caffeine • Nicotine • Sugar • Alcohol • Concussions • Talk Radio • Nightly News • Political Campaigns Be intentional!

23. “Functional Aging” (JE Birren,1966) • All systems are affected by the aging process, but dysfunction can be greatly minimized, as exemplified by Master Athletes. • The base rate of the heart begins to slow soon after birth, but attendant physical drop-off is postponed at least two decades. • Birren: “An infinitely eliminable variable.” • Moses: “120 years” (Genesis 6:3)

24. Intentional Aging • Fluid intelligence and crystallized intelligence complement through middle adulthood. • In older adulthood crystallized intelligence must be developed with intention to effectively offset decreased fluid intelligence. • Recent research demonstrates that fluid intelligence can also be developed after middle adulthood!

25. Intentional Aging • Just-right challenges in tasks such as learning a new language or musical instrument, or reading in a new area that one finds difficult. • Although brain injury, stroke or disease significantly accelerate onset of dementia, intentional aging postpones dysfunction. • Just-Right Challenges are found everywhere!

26. Functional Losses of Dementia • Awareness & Orientation • Attention & Concentration • Memory: Registration& Recall • Receptive and expressive language • Novel problem solving • Judgment • Cognitive Reserve Capacity

27. Stage Model of Neurorehabilitation Build-Up Cognitive Reserve Capacity

28. Limit the Effects of DementingCauses • Cognitive reserve capacity provides a buffer between the dementing causes and the onset of functional decline. • Improving cognitive reserve capacity postpones the onset of dysfunction.

29. Activation - Performance Curve Performance Maximum Peak Performance Window “The Zone” “Flow” Optimum Activation Yerkes & Dodson (1908)

30. Activation - Performance Curve Performance Notice ceiling and slope effects. Maximum Peak Window Optimum Activation

31. Cognitive Reserve Capacity Cognitive reserve capacity in the left temporal lobe is the buffer between language processing ability and demand. When exceeded, we have inability, also known as dementia.

32. Neurorehabilitation • Neuroplasticity accommodates impairments and improves cognitive reserve capacity. • Neurogenesis improves through stress reduction and strategies for brain health. • Minimum Daily Requirements: • 30/60 Aerobic Exercise • Healthful allostatic load / Stress modulation • Proper nutrition & chemical intake • Brain Restorative Sleep • Several Just-Right Challenges

33. Useful Resources www.Goalinginstitute.com • AARP: http://www.aarp.org/health/brain-health/ • Lumosity: http://www.lumosity.com/about • Posit Science: http://www.positscience.com/ • Doidge: “The Brain That Changes Itself” (2007) • BryckRL, Fisher PA. Training the brain: Practical applications of neural plasticity from the intersection of cognitive neuroscience, developmental psychology, and prevention science. American Psychologist. 2012;67(2):87-100.