There are three ailments that most of us fear as we get older: losing our mental capacities, cardiovascular disease and cancer. In deference to reading time and latest articles, I am only going to deal with one, dementia. As I perused this month’s issue of the Journal Menopause (did I ever mention that its cover is bright red?), I found an article that summarized much of the data on dementia. Over a century ago, Dr. Alois Alzheimer, a German physician, reported on his treatment and subsequent autopsy examination of a female patient (Frau August Deter… there were no HIPAA regulations regarding names at that time) who developed dementia in midlife. Among her symptoms: hallucinations, paranoia, hostility, severe memory impairment, diminished cognition and language disturbance. She rapidly deteriorated, becoming bedridden, incontinent and completely helpless. At autopsy, Dr. Alzheimer found dramatic atrophy of her brain and on microscopic exam the neurons were surrounded by deposits of protein and had degenerated. We now know that the disease named after Dr. Alzheimer (AD) is the preeminent cause of dementia and is one of the most serious public health issues facing baby boomers as we age.

The development of Alzheimer’s disease is now thought to be influenced by many factors that include inherited gene susceptibility, environmental exposures, midlife health status, education and lifestyle choices. We also know, however, that the “older” brain has the ability to form new neurons and improve on the connection of old ones; in other words our brains have “placidity” and “cognitive reserve”. Alzheimer’s is the end result of a spectrum of mental declines and begins with mild cognitive impairment. So are there ways to prevent or delay that decline? And what can we do to maintain our brain fitness? (And if you remember, this is the intent of my somewhat cute website title.)

Here are some of the factors and prevention activities reported in the article:

Cognitive training: We’ve been told in books, magazine articles and PBS specials to engage in stimulating activities. Studies have been done which show that learning to play musical instrument lessons, memory games and learning a second language demonstrate some promise in early AD, but overall the effectiveness of these activities is, according to the authors, equivocal. They point out, however, that it can’t hurt…. (By the way, those of us who are bilingual are less likely to develop AD and lifelong bilingualism appears to delay the onset of dementia by approximately 4 years!)

Social engagement: Here is where I can add that volunteering activities have been found in some research to improve cognitive functions and mental health in seniors.

Health factors: The decidedly negative factors that increase risk of AD are the usual issues every doctor tries to help treat: obesity, atherosclerosis, high cholesterol, hypertension, smoking and diabetes. Diagnosing and treating them at an early stage should help prevent the mental consequences.

Diet: A diet rich in nuts, fish, fruits and vegetables – the so-called Mediterranean diet – is associated with a reduced risk of dementia and AD. One study that is cited in the review found that the dietary pattern that was significantly associated with reduced AD risk was a diet rich in omega-3 and omega-6 polyunsaturated acids, vitamin E, and folate and low in saturated fatty acids and vitamin B12. To get the brain-right nutrients we have to have a diet rich in dark and leafy vegetables, salad dressing, nuts, fish, tomatoes, poultry, cruciferous vegetables, and fruits, while refraining as much as possible from high-fat dairy, red meat organ meat and butter. And although it might seem easier to just take dietary supplements containing antioxidants or the omega fatty acids, know that most randomized controlled studies comparing nutrient supplements with placebo have not consistently found that they protect against cognitive decline. Apparently, we need to actually eat the foods in order to get an interaction of their nutrients to support our brains.

Physical exercise: Greater amounts of physical activity over the course of one’s lifetime are associated with a reduced risk of dementia. And it seems that there are positive effects of exercise in later life. In one study, 130 older adults (mean age 67.7 years) without dementia were randomly assigned to either an aerobic exercise training group of 30 minutes of brisk walking three times a week for 1 year or stretching in the control group. Exercise training actually increased the volumes in certain areas of the brain and memory scores on tests in the exercisers, while the control group had a decrease in the same areas in their brains and a decline in their memory scores over just the 1 year study period. I think that the data on exercise and brain health is extraordinarily convincing. And yes, I went to the gym today!

Bottom line (finally): Keep your brain engaged with mental challenges, don’t let yourself become isolated and if you have free time, volunteer (call me about Save the Children). Moreover, don’t smoke, try to maintain an appropriate weight, make sure you get your cholesterol and glucose levels down to optimal levels, get your brain nutrients through the right kind of diet (don’t rely on supplements to do it), and make exercise a vital part of your daily routine. All this may help prevent loss of a piece or peace of mind.

I have routinely recommended that my patients err on the higher side of D (which sounds like the grade advice I gave to my kids) and that they supplement 1,000 IU’s of Vitamin D a day. (I do). I felt exonerated when I read the report in the July issue of The New England Journal of Medicine that corroborated my suggestion, at least with regards to fracture prevention in women over 65. The authors pooled data from 11 double-blind randomized controlled trials of oral vitamin D with or without calcium. (The participants who were 65 and older were randomly assigned to take Vitamin D and compared to those assigned to control groups). The 11 studies included 31,022 persons (mean age, 76; 91% women) who had 1111 hip fractures and 3770 nonvertebral fractures.

There were both unexpected and expected findings. Although some previous meta-analyses (where multiple studies, not necessarily double-blinded or controlled were combined) suggested that the dose of vitamin D is irrelevant when it is combined with calcium, this pooled analysis did not. On the contrary, the authors found that the risk of fracture with combined supplementation was reduced only at the highest intake-level of vitamin D and moreover, a smaller amount of calcium supplementation (less than 1000 mg per day) was more beneficial in reducing risk of fracture than a larger amount (greater than 1000 mg per day).

They also calculated the difference in fracture rate based on vitamin D supplement doses. This was done by comparing quartiles of vitamin D intake (the lowest, next to lowest, next to highest, as well highest amounts… I feel rather stupid writing it this way, just remember that quartile means a quarter, so they divided the participants into 4 groups according to the amount of Vitamin D they actually took). The risk of fracture decreased only at the highest quartile (800 IU daily), with a 30% reduction in the risk of hip fracture and a 14% reduction in the risk any other nonvertebral fractures. The fracture benefit at the highest level of vitamin D intake was fairly consistent across all age groups, type of dwelling and additional calcium intake.

Bottom line: if you are 65 or older, take at least 800 IU’s of vitamin D a day. And if you are younger (my advice is not a part of this study), get into the habit of making sure you get your D.

Most of us know our total cholesterol level and can differentiate between  the good cholesterol (HDL-C) and bad cholesterol (LDL-C). Do we need to have our physicians order additional blood tests in order to evaluate our risk of cardiovascular disease (CVD)?

Before I delve into the predictive power of blood tests, I have to remind you that the major risks for cardiovascular disease (heart attack and stroke) are obesity, hypertension, smoking, diabetes and advancing age.

An article published in the June 20 issue of JAMA (my birthday!) assessed the value of other lipid-related markers for assessment of cardiovascular disease risk. The authors reported on a collaboration of 37 US centers in which the records of 165,544 individuals were surveyed and followed for a median of 10.4 years. The group was appropriately called the Emerging Risk Factors Collaboration Group

The levels of surface proteins surrounding cholesterol were measured in addition to those of total cholesterol and HDL-C in all the participants. The premise was that perhaps high levels of these proteins (called apoprotein B and apoprotein A-1) make the cholesterol more likely to “stick” and cause plaque. If so, these lipoproteins might be more strongly related to heart attack and stroke risk than the level of the cholesterol contained within them. And, the researchers postulated that perhaps measurement of these lipoproteins would augment risk assessment or even replace the need to measure cholesterol levels in individuals who have no known cardiovascular disease.

A very tedious assessment of the medical records for the 165,544 participants with no known CVD at recruitment was carried out. There were slightly more women than men. Their average age at onset of the study was 56. During follow-up of 7 to 14 years, the individuals in the study suffered 10,132 heart attacks and 4,994 strokes. (I give you these numbers to remind you that CVD is an enormous cause of severe morbidity and mortality.) When the blood tests at the onset of the study were analyzed as to their predictive power for risk assessment, the researchers found that replacing knowledge of cholesterol levels with the apoprotein markers did not improve risk assessment and actually worsened CVD prediction.

Bottom line: You don’t need extra “new” lipid markers to determine your risk for heart attack and stroke. Baseline measurements of total cholesterol and HDL cholesterol levels remain the golden standard for prediction.

Links

-->