It’s never too early nor too late!
Naareed Makadam, one of the scientists on the Lancet Commission made this statement during a question and answer session after the Lancet Commission’s presentations at the Alzheimer’s Association International Conference 2020.
The statement in context: “Individuals can see this very hopeful message that it’s never too early, and it’s never too late to start addressing dementia risk and whatever your genetic status is—you don’t even need to know your genetic status-making healthier lifestyle changes will help.” [5]
Gill Livingston, the lead researcher on the Lancet Commission’s report said, “Whether you’ve got the genes or you haven’t got the genes, changing what you do and how you do it seems to improve your risk and reduce the chance of having dementia.” [5]
This section on individual factors will cover:
Part 1: Results of the Lancet Commission’s study of risk factors that could reduce the prevalence of dementia in the overall population
Part 2: Other specific factors that could reduce an individual’s risk of dementia:
- Avoid drugs that could increase risk of cognitive decline or worsen existing cognitive decline
- Get help for sleep problems
- Take care of your dental health
- Take care of your vision
Part I: Specific risk factors that could reduce the prevalence of dementia in the overall population: the Lancet Commission
At the 2020 Alzheimer Association International Conference, the Lancet Commission on Dementia Prevention, Intervention and Care updated their 2017 report. The commission brings together multiple experts and does an extensive review and meta-analysis of current literature. In 2017, they estimated that if certain factors were eliminated in the population as a whole, that 35% of dementia could be prevented. In 2020, they added 3 additional factors, bringing the total number of risk factors supported by research to 12 and estimating that if these risk factors were eliminated in the populatioin as a whole, prevalence of dementia could be reduced by 40%. [1]
They organize their findings by lifestage.
As you look over the risk factors, it is certainly wise to address the risk factors in your own life . However, keep in mind that the percentages next to each risk factor represent the reduction in the prevalence of dementia in the population, NOT your individual reduction in risk if you eliminate that factor. (It could be higher or lower.) [1]
Here is a nice graphic from their report that the Lancet posted on Twitter (you need to click on graphic so that you can see the whole thing) :
NEW—40% of #dementia cases could be prevented or delayed by targeting 12 risk factors throughout life: finding from 2020 update to @TheLancet Commission on dementia prevention, intervention, and care #AAIC20 https://t.co/Sr50fS3w68 pic.twitter.com/QoRF8EQFAc
— The Lancet (@TheLancet) July 30, 2020
Remember, these percentages are the reductions in prevalence in a population if these risk factors were eliminated.
This doesn’t tell you how much you lower your own risk by treating or eliminating any of these factors.
“Risk factors that are more common account for a higher percentage of population risk. For instance, the authors estimate that eight percent (8%) of all dementia cases could be associated with poor early school education; and five percent (5%) could be associated with smoking. While the mechanism linking education, hypertension, diabetes and smoking to dementia is relatively well understood, the recognition of hearing loss as a potential risk factor is still new, and the research is at an earlier stage.” [2]
In case it’s hard to read the diagram, here are the factors:
Youth
- Not completing secondary education 7.1% +
Midlife
- Hearing loss 8.2 %
- Traumatic Brain Injury 3.4% *
- Hypertension 1.9%
- Alcohol intake above 21 units/wk .8% *
- Obesity .7% +
Later Life
- Smoking 5.2%
- Depression 3.9%
- Social isolation 3.5%
- Air pollution (or second hand smoke exposure) 2.3% *
- Physical inactivity 1.6%
- Diabetes 1.1%
*New in 2020 [1]
+ Other studies suggest additional factors should be considered at these points in the lifespan:
Youth: A study of African American youth showed that having diabetes, high blood pressure, or two risk factors for cardiovascular disease were associated with increased risk of later life cognitive decline. [4]
Middle Adulthood: Higher BMI (Body Mass Index) between ages 20-49 led to an increase of 1.8x the risk for women in the overweight category and 2.5x the risk for women who were obese. [4]
What you can do to decrease your individual risk from these factors according to the Commission:
The Commission recommends the following for individuals: [2] [3]
- Aim for systolic blood pressure of 130 mm Hg or lower beginning in midlife [age 40]; other studies suggest intervention at a younger age [4]
- Use hearing aids for hearing loss
- Take steps to prevent head trauma [e.g. from falls, accidents, sports, etc.]
- Stop smoking, even later in life to decrease your risk [Secondhand smoking is also a risk.]
- Reduce obesity and diabetes by healthy diet and exercise
- Stay physically active in midlife and later life
- Stay “cognitively, physically and socially active in midlife and later life” [3]
- “Sustained exercise in midlife, and possibly later life, protects from dementia, perhaps through decreasing obesity, diabetes, and cardiovascular risk.” [3] [emphasis mine]
Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.
[2] Summary of Lancet review [3] 2020 Lancet [4] 5 Takeaways from the 2020 Alzheimer’s Association International Conference [5] Personal notes from the Q&A session after the presentations by Lancet Commission members at the Alzheimer’s Association International Conference 2020.
Part 2: Other specific factors that may impact your risk of cognitive decline:
1. Make sure any medications you’re taking do not unnecessarily increase your risk or accelerate any cognitive decline you may have:
Note: There are often alternative drugs that will treat your condition without increasing your risk. Other times, you and your doctor may have to weigh the risk versus the benefit of a particular medication.
The American Geriatric Society puts out a list to help primary care physicians stay on top of the research on drugs that may be counterindicated for older individuals. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Except as noted, this document is the source of information in this section.
There is a strong recommendation against using benzodiazepines as these drugs may “increase the risk of cognitive impairment
Benzodiazepines also increase the risk of falls, accidents, etc. Common brand names for Benzodiazepines include Xanax, Valium, and Ativan. See Table 2 p.7
For people who have cognitive impairment or dementia, there is a strong recommendation to avoid several categories of drugs including anticholinergics, benzodiazepines and some other categories for “adverse effects on the CNS [Central Nervous System].”
See Table 3, p. 10-11 for a complete list
Anticholinergic drugs include many common categories of drugs some of which are sold over-the-counter:
See Table 7 p. 17 for a comprehensive list of the generic names of the drugs in this category. I’ve included some common brand names of these generic medicines.
- Certain antidepressants: Two common brand names of antidepressants that are also anticholeric are Elavil and Paxil. There are other antidepressants that are safe for older adults with cognitive impairment to use.
- Certain medications to control urinary incontience
- Certain anti-spasmodics and muscle relaxants including one used for motion sickness(See the table for a comprehensive list)
- Certain antihistamines : Many of these are available over-the-counter for allergy relief or as sleep aids. A few examples: Benadryl and Unisom as well as products sold as a combination of pain reliever and sleep aid, such as Tylenol PM, Advil PM, Aleve PM. [2] This is not a comprehensive list! You’ll need to check Table 7, p 17 for the complete list. OTC medications are not necessarily safe for use by older adults. Check with your pharmacist or physician before using any OTC medication.
- Other categories of drugs
Note: Not all physicians are familiar with the list above, especially if they are not a geriatric doctor or neurologist, so it’s important that patients bring the issue up with their medical provider. You can also double-check with your pharmacist, including for any medications you have purchased over the counter.
2. Get help for sleeping difficulties:
The Lancet Commission concluded that at the present time, there is not enough evidence to include sleep duration as a risk factor across a population at this time.
Does that mean that sleep is not important? Consider this:
Several of the Worldwide FINGER studies being done around the world are including sleep as one of the conditions they are gathering data on.
Sleep quantity and quality does affect conditions which themselves are risk factors for dementia:
The Lancet study noted that hypertension, obesity , and diabetes were risk factors for dementia.
The CDC states that hypertension, obesity, and diabetes are all negatively impacted by sleep durations less than 7 hours. [2] Other research has linked cardiovascular issues to the development of Alzheimer’s disease . [6]
Insomnia:
Additionally , with regard to insomnia, the CDC states:
“Insomnia is linked to high blood pressure and heart disease. Over time, poor sleep can also lead to unhealthy habits that can hurt your heart, including higher stress levels, less motivation to be physically active, and unhealthy food choices.” [2]
Sleep Apnea:
With regard to sleep apnea, the article from the CDC states:
“Sleep apnea affects how much oxygen your body gets while you sleep and increases the risk for many health problems, including high blood pressure, heart attack, and stroke.”
Damage to grey matter:
“patients with Obstructive Sleep Apnea syndrome demonstrated reduced brain gray matter concentration. “Gray matter” refers to the cerebral cortex, where most information processing in the brain takes place.
Principal investigator Seung Bong Hong, MD, PhD explained, “…poor sleep quality and progressive brain damage induced by OSA (Obstructive Sleep Apnea) could be responsible for poor memory, emotional problems, decreased cognitive functioning and increased cardiovascular disturbances… The use of continuous positive airway pressure – CPAP – therapy could stop further progression of brain damage in patients with severe OSA.” [3].
Damage to white matter, which can be reversed with treatment:
” [Study] participants with severe, untreated sleep apnea had a significant reduction in white matter fiber integrity in multiple brain areas. This brain damage was accompanied by impairments to cognition, mood and daytime alertness. Although three months of CPAP therapy produced only limited improvements to damaged brain structures, 12 months of CPAP therapy led to an almost complete reversal of white matter abnormalities. Treatment also produced significant improvements in nearly all cognitive tests, mood, alertness and quality of life. [4]
Evidence of a direct link between sleep apnea and dementia
A study found that elderly women with sleep apnea had 2x the risk of developing dementia over the next 5 years than those without sleep apnea. [7]
“The findings, published in the August 10, 2011 issue of the Journal of the American Medical Association, showed for the first time what sleep specialists have long suspected but hadn’t proved: that sleep apnea, also known as sleep-disordered breathing, can deprive the brain and other organs of the oxygen they need and, may, over time, trigger declines in cognitive ability.
“This is the first study to show that sleep apnea MAY lead to cognitive impairment,” said study leader Kristine Yaffe, MD, professor of psychiatry, neurology and epidemiology at UCSF and chief of geriatric psychiatry at SFVAMC. “It suggests that there is a biological connection between sleep and cognition and also suggests that treatment of sleep apnea might help prevent or delay the onset of dementia in older adults.”
“While we cannot conclude from these results that SDB causes cognitive impairment, our study suggests that it may at least be a contributing factor,” said Yaffe.” [7]
[2] CDC: how sleep affects heart health [3] https://www.sleepfoundation.org/articles/sleep-apnea-and-progressive-brain-damage [4] American Academy of Sleep Medicine: Sleep Apnea Brain Damage is Reversible [5] Not quoted yet; refers to 2017 AAIC AARP: Does Sleep Apnea Lead to Alzheimer’s [6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6542637/ [7] Sleep apnea associated with double risk of dementia
3. Take care of your dental health
“We looked at people’s dental health over a 20-year period and found that people with the most severe gum disease at the start of our study had about twice the risk for mild cognitive impairment or dementia by the end,” said study author Ryan Demmer, an associate professor at the University of Minnesota School of Public Health in Minneapolis” [1]
Why would this be? The lead researcher suggested two possible mechanisms:
The first possibility is direct: The bacteria in your mouth are the direct cause.
Ryan Demmer: “The oral microbiome is central. My core hypothesis is that bacteria in the mouth that cause periodontal disease, are also a cause of systemic outcomes (cardiovascular disease, dementia etc.),” [1]
But the connection could also be indirect: since we have reason to believe that these bacteria contribute to other conditions, which are themselves known to increase risk for dementia. It might be these factors serve as a link between oral bacteria and the risk of dementia:
“There is a robust body of literature suggesting that chronic periodontal infections might contribute to insulin resistance, prediabetes, incident diabetes and incident stroke,” Demmer said. “Accordingly, insulin resistance, diabetes and stroke are strong predictors of future cognitive decline.” [1] [1] Gum disease associated with increased risk of dementia
[2] This is the actual study Neurology: Peridontal Disease and Incident Dementia4. Take care of your vision as well as your hearing
“In the study of 2,051 older adults (22.8% with hearing or visual impairment and 5.1% with both impairments) who were followed over eight years, dual sensory impairment was associated with an 86% higher risk for dementia compared with having no sensory impairments. During follow-up, dementia developed in 14.3% in those with no sensory impairments, 16.9% in those with one sensory impairment, and 28.8% in those with dual sensory impairment.” [1]
“Participants with dual sensory impairment were also twice as likely to develop Alzheimer’s disease … than those without sensory impairments.” [1]
The study was published in Alzheimer’s & Dementia: Diagnosis, Assessment & Disease Monitoring.
Macular degeneration is a common form of visual impairment in aging, Caucasian adults and can lead to blindness.
What if it runs in my family?
Having a relative with macular degeneration increases your risk, but there are things you can do to lower that risk.
“…modifiable risk factors also play an important role when it comes to developing macular degeneration. According to the National Eye Institute, you can reduce your risk by :”
- Get regular eye exams at least once a year once you are 60 [10]
- Quit smoking. [10]Smoking cigarettes can double your risk of the condition. [2] Even if you do not smoke, living with a smoker can almost double your risk after 5 years. [7]
- Maintain a healthy blood pressure and act to lower high cholesterol [2] [10]
- Eat a healthy diet, one high in nutrients from green leafy vegetables and fish [2] [10] Other dietary advice includes eating foods with high levels of zinc, using healthy, unsaturated oils such as olive oil, and consuming a diet high in Omega 3s. (Fish oil capsules don’t have the same effect.) [5]
- Reduce exposure to UV light; wear sunglasses [9]
- Maintain a healthy weight [5] [10]
- Exercise regularly [3-5], [10]
- Specially formulated dietary supplements may help, but should only be taken under direction of your doctor because the high levels of certain vitamins such as Vit E can increase risk of heart failure [5] and supplements containing beta-carotene can increase risk of lung cancer in smokers. Your doctor can work with you to discuss the benefits and risks for you as an individual.
The two specific nutrients in green leafy vegetables that are believed to help prevent macular degeneration are lutein and zeaxanthin. Chart of lutein and zeanthin content of various vegetables.
Foods high in zinc include shellfish (especially oysters), mammal meat (especially beef), poultry (especially dark meat), and dairy (especially nonfat yogurt) . Plant sources of zinc include tofu, legumes, seeds (hemp, pumpkin/squash), oatmeal & fortified cereals & vegetables such mushrooms & peas. The zinc in animal products is more bioavailable than what is found in plants. Watch the serving sizes listed on the chart; they are not always single serving sizes. 100 g= about 3.5 oz. [8]
Foods high in Omego -3s DHA and EPA are fatty fish such as salmon, mackerel, trout, and sardines. Plants sources of Omega-3’s are in the form of ALA. Flax and chia seeds are especially high. Other plant sources are walnuts, soy, beans, cruciferous vegetables, and a few fruits such as avocado or raspberries. [11]
There is a synergistic effect of family history, smoking, eating fewer fruits and vegetables, and low levels of exercise. Women who had all 4 risk factors had 4 x the risk of women with none of the risk factors. [6]
Interesting, isn’t it? The same habits that help reduce your risk of cognitive decline can also reduce your risk of macular degeneration.
[1] Effect of both vision and hearing impairments on risk of cognitive decline [2] Harvard Health: How Can I Avoid Macular Degeneration? [3] UVa announcement of study results [4] More details from UVA study [5] Mayo Clinic: Lifestyle Choices for Slowing Down Macular Degeneration [6] Diet, Smoking, Exercise, and Genes Interact to Affect AMD Risk [7] Passive smoking almost doubles risk of degenerative eye disease [8] https://www.myfooddata.com/articles/high-zinc-foods.php [9]UV and Blue Light Aggravate Macular Degeneration [10] NIH publication [11] https://www.myfooddata.com/articles/high-omega-3-foods.php5. Getting a flu shot and/or pneumonia vaccine may reduce risk for Alzheimer’s
Two studies presented at the Alzheimer’s Association International Conference 2020 indicated that flu shots and pneumonia vaccines may be protective and reduce the risk of Alzheimer’s. This data showed association, not cause. More research needs to be done to establish the link. It is possible that 1) people who get flu shots and pneumonia vaccines may simply take better care of their health, and that accounts for the risk reduction or that 2) since both flu and pneumonia impact the brain not getting them reduces a person’s risk of Alzheimer’s or 3) that the stimulation of the immune system helps protect against Alzheimer’s or some other factor. It’s always wise to discuss the pros and cons of a decision to get a flu shot or pneumonia vaccine with your physician.
[1] Flu shots and pneumonia vaccine may reduce risk of Alzheimer’s [2] FLu and penumonia shots may lower your risk for Alzheimer’s