healthy brain aging

Healthy Brain AgingHealthy Brain Aging

November 2, 2012

Brian S. Appleby, M.D.

Staff, Lou Ruvo Center for Brain Health

No Relevant Financial Disclosures

No Relevant Financial Disclosures

ObjectivesObjectives

• Describe why healthy brain aging is important

• Summarize current knowledge about brain aging

• Describe ways to approach aging patients regarding brain health

WHY IS IT IMPORTANT?WHY IS IT IMPORTANT?Healthy Brain Aging

19.3% of population

Rank Cause of death 2010 Age-adjusted death rate

% change from 2009

1 Heart disease 178.5 -2.4

2 Cancer 172.5 -0.6

3 Chronic lung disease 42.1 -1.4

4 Cerebrovascular disease 39 -1.5

5 Accidents 37.1 -1.1

6 Alzheimer’s disease 25 +3.3

7 Diabetes 20.8 -1

Adapted from: NVSR, 60(4)

2011 Alzheimer’s Disease Facts and Figures

2011 Alzheimer’s Disease Facts and Figures

2011 Alzheimer’s Disease Facts and Figures

2011 Alzheimer’s Disease Facts and Figures

2011 Alzheimer’s Disease Facts and Figures

Dementia caregiver spouses had 6 times the risk of incident dementia compared to those who

had spouses without dementiaNorton MC, J Am Geriatr Soc 2010

Work Force ConcernsWork Force Concerns

• 57 new geriatric psychiatrists certified per year

• 54/120 (45%) training spots filled per year

• Now: 1 geri psych doc per 23,000 patients

• 2030: 1 geri psych doc per 27,000 patients

ABPN, 2010 Annual ReportJeste DV, Psychtri News 2012

WHAT IS IT?WHAT IS IT?Healthy Brain Aging

Emery V, 2011

Non-Modifiable Risk Factors for Alzheimer’s Disease (AD)

Non-Modifiable Risk Factors for Alzheimer’s Disease (AD)

• Age• Genetic

- PS1, PS2, APP mutations (pathogenic)

- APOε4 roughly doubles risk (risk factor)

In a NutshellIn a Nutshell

Chronic Diseases

EngagementLifestyle

Increased risk for cognitive declineIncreased risk for cognitive decline

All low level of evidence• Low plasma selenium• Depression• Diabetes• Metabolic syndrome• Current tobacco use

Williams JW, AHRQ Publication No. 10-E005 2010

Increased risk factors for ADIncreased risk factors for AD

Moderate Level of Evidence

• Conjugated equine estrogen + methyl progesterone

Low Level of Evidence

• Some NSAID’s• Depression• Diabetes• Mid-life hyperlipidemia• Traumatic brain injuries in ♂• Pesticide exposure• Never married, less social

support• Current tobacco use

Williams JW, AHRQ Publication No. 10-E005 2010

Rodrigue KM 2012

Vemuri P, 2012

Singh-Manoux 2012

Pimentel-Coelho PM 2012

Dotson VM 2010

Double Trouble Diabetes and Depression

Double Trouble Diabetes and Depression

Katon W, Arch Gen Psychiatry 2011

Solomon A, 2012

Decreased risk for cognitive declineDecreased risk for cognitive decline

High level of evidence• Cognitive training

Low level of evidence• Vegetable intake• Mediterranean diet• Omega-3 fatty acids• Physical activity• Non-cognitive, non-

physical leisure activities

Williams JW, AHRQ Publication No. 10-E005 2010

Decreased risk factors for ADDecreased risk factors for AD

All are low level of evidence• Mediterranean diet• Folic acid• Statins• Higher level of education• Light-moderate alcohol use• Cognitively engaging activities• Physical activity

Williams JW, AHRQ Publication No. 10-E005 2010

Memory Fitness ProgramMemory Fitness Program

Structure• Biweekly classes• 60 min in length• Lasted 6 weeks• Given materials• Given homework

Content• Brain health education• Memory strategies• Diet• Exercise • Stress reduction

Miller KJ, Am J Geriatri Psychiatry 2012

Improved objective and subjective aspects of memory

NutrientVitamin EVitamin CFolateVitamin B12Vitamin DBeta-caroteneOmega-6-polyunsaturated fatty acidsSaturated fatty acidsMonounsaturated fatty acidsOmega-3-polyunsaturated fatty acids

p value0.750.130.260.450.750.780.960.840.920.02

Gu Y, Neurology 2012

Ω-3 PUFA SourcesΩ-3 PUFA Sources

Food Correlation CoefficientSalad Dressing 0.53Fish 0.44Poultry 0.30Margarine 0.19Nuts 0.09

Gu Y, Neurology 2012

HOW TO APPROACH PATIENTS?

HOW TO APPROACH PATIENTS?

Healthy Brain Aging

Vemuri P, 2012

Interventions(Delay Onset of AD)

Interventions(Delay Onset of AD)

• Evaluate current medications• Evaluate and treat AD risk factors• Systemic mental exercise• Physical exercise• Treatment non-cognitive causes of

disability• Supportive psychotherapy

Emery V, 2011

Address Medical Risk FactorsAddress Medical Risk Factors

• Cerebrovascular disease• Cardiovascular disease• Diabetes• Hyperlipidemia• Elevated homocysteine levels• Head injury• Obesity

Emery V, 2011

Address Trouble MedicationsAddress Trouble Medications• Sedatives: benzodiazepine & derivatives• Antidepressants: TCAs, paroxetine• Antipsychotics• Antihypertensives: reserpine, clonidine• Anticholinergics: oxybutinin, antihistamines• H2 blockers: cimetidine, ranitidine• Opiates• Corticosteroids• Antibiotics: floroquinolones

Vigen C, Am J Psychiatry 2011

Address Neuropsychiatric Risk Factors

Address Neuropsychiatric Risk Factors

• Mood disorders• Anxiety• Stress

Emery V, 2011

Address Lifestyle Risk Factors

Address Lifestyle Risk Factors

• Education• Caretaker of spouse with dementia• Environmental exposures• Nutrition• Substance abuse/misuse• Smoking• Sleep

Emery V, 2011

My ApproachMy Approach

Heart Healthy

Cognitive Engagement

Regularly Scheduled Social Engagement

Heart HealthyHeart Healthy

• “Anything associated with keeping your heart healthy.”

• Physical exercise• Low fat, low cholesterol diet• No smoking

Physical ExercisePhysical Exercise

“Physical exercise on more days then not for at least 30 min at a pace that you

cannot carry a conversation.”

Regular Cognitive Engagement

Regular Cognitive Engagement

• ANY mentally stimulating activity- Reading- Puzzles- Games- Musical instruments

• Pick what you may already be doing• Pick what you like doing

Regular Scheduled Social Engagement

Regular Scheduled Social Engagement

• Regular: AT LEAST once weekly• Scheduled: Combats apathy, supplies

structure• Does not include errands or chores

• Disease• Life Story• Dimensions

(Personality)• Motivated Behaviors

ReferencesReferences

• Dotson VM, Beydoun MA, Zonderman AB. Recurrent depressive symptoms and the incidence of dementia and mild cognitive impairment. Neurology 2010;75:27-34.

• Emery VOB. Alzheimer disease: Are we intervening too late? Pro. J Neural Trans 2011;118:1361-1378.

• Gu Y, Schupf N, Cosentino SA, et al. Nutrient intake and plasma beta-amyloid. Neurology 2012;78:1832-1840.

• Jeste DV. Aging and mental health: Bad news and good news. Psychiatr News 2012; 4:3.

• Katon W, Lyles CR, Parker MM, et al. Association of depression with increased risk of dementia in patients with type 2 diabetes: The Diabetes and Aging Study. Arch Gen Psychiatry 2012;69:410-417.

ReferencesReferences

• McHugh PR & Slavney PR. Perspectives of Psychiatry. The Johns Hopkins University Press, 2nd edition, 1998.

• Miller KJ, Siddarth P, Gaines JM, et al. The memory fitness program: Cognitive effects of a healthy aging intervention. Am J Geriatri Psychiatry 2012;20:514-523.

• Norton MC, Smith KR, Ostbye T, et al. Greater risk of dementia when spouse has dementia? The Cache County study. JAGS 2010; 58:895-900.

• Pimentel-Coelho PM & Rivest S. The early contribution of cerebrovascular factors to pathogenesis of Alzheimer’s disease. Eur J Neurosci 2012;35:1917-1937.

• Rodrigue KM, Kennedy KM, Devous MD, et al. Beta-amyloid burden in healthy aging: Regional distribution and cognitive consequences. Neurology 2012;78:387-395.

ReferencesReferences

• Singh-Manoux A, Czernichow C, Elbaz A, et al. Obesity phenotypes in midlife and cognition in early old age: The Whitehall II cohort study. Neurology 2012;79:755-762.

• Solomon A, Kivipelto M, Soininen H. Prevention of Alzheimer’s disease: Moving backward through the lifespan. J Alzheimer Dis 2012 [In Press].

• Vemuri P, Lesnick TG, Przybelski SA, et al. Effect of lifestyle activities on AD biomarkers and cognition. Ann Neurol 2012 [In Press]

• Vigen CLP, Mack WJ, Keefe RSE, et al. Cognitive effects of atypical antipsychotic medications in patients with Alzheimer’s disease: Outcomes from CATIE-AD. Am J Psychiatry 2011;168:831-839.