LN Matheson, PhDGoaling Institutewww.GoalingInstitute.com

Postponing Dementia, and …1

LN Matheson, PhDGoaling Institutewww.GoalingInstitute.com

… Staying Smarter Longer2

Stage Model of Neurorehabilitation

Stage Area Assessed Measured by, or in terms of …

8 Earning Capacity Earned income over expected work-life.

7 Vocational Handicap Ability to perform a particular job.

6 Employabil ity Abil ity to become employed in the local labor market.

5 Vocational Feasibil ity Abil ity to perform fundamental work behaviors.

4 Occupational Disability Vocational, societal and familial l imitations.

3 Dysfunction Inabil ity to perform component actions and tasks.

2 Impairment Loss or restriction of person component.

1 Pathology & Diagnosis Imaging, lab studies, observed signs, reported symptoms.

3

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.

4

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

5

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.

6

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)

7

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.

8

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.

9

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.

10

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.

11

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

12

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.

13

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.

14

Differentiate Dementia from Disease

Dementing causes begin 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.

15

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.

16

Methods to Detect Dementing Causes

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

17

PET + MRI Scan18

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.

19

Dementing Causes 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

20

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

21

Dietary Prophylaxis Restrictions

Caffeine Nicotine Sugar Alcohol Concussions Talk Radio Nightly News Political Campaigns

Be intentional!

22

“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)

23

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!

24

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!

25

Functional Losses of Dementia

Awareness & Orientation Attention & Concentration Memory: Registration & Recall Receptive and expressive language Novel problem solving Judgment

Cognitive Reserve Capacity

26

Stage Model of Neurorehabilitation

Build-Up Cognitive Reserve Capacity

Stage Area Assessed Measured by, or in terms of …

8 Earning Capacity Earned income over expected work-life.

7 Vocational Handicap Ability to perform a particular job.

6 Employabil ity Abil ity to become employed in the local labor market.

5 Vocational Feasibil ity Abil ity to perform fundamental work behaviors.

4 Occupational Disability Vocational, societal and familial l imitations.

3 Dysfunction Inabil ity to perform component actions and tasks.

2 Impairment Loss or restriction of person component.

1 Pathology & Diagnosis Imaging, lab studies, observed signs, reported symptoms.

27

Limit the Effects of Dementing Causes

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.

28

Activation - Performance Curve

MaximumPerformance Peak Performance Window

“The Zone”“Flow”

OptimumActivation Yerkes & Dodson

(1908)

29

Activation - Performance Curve

MaximumPerformance Peak

Window

OptimumActivatio

n

Notice ceiling and slope effects.

30

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.

31

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

32

Useful Resourceswww.Goalinginstitute.com

1. AARP: http://www.aarp.org/health/brain-health/2. Lumosity: http://www.lumosity.com/about3. Posit Science: http://www.positscience.com/4. Doidge: “The Brain That Changes Itself” (2007)5. Bryck RL, 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.

33