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By Mary Carpenter
LAST WEEK’S announcement of Rosalynn Carter’s dementia has highlighted recent news and questions about the condition—as well as the work Carter has done to encourage “society not to fear people with mental illness,” according to the New York Times. At a 1977 international conference on mental health, Carter said, “We must create a climate in which our most vulnerable are accepted. We must start first with them.”
Dementia—affecting about one in 10 adults ages 65 and older in the U.S. —is the umbrella term for symptoms (several of them sometimes occurring simultaneously) of progressive, irreversible cognitive decline that can arise in a handful of distinct conditions. In 2020, Alzheimer’s Disease (AD), the most common cause of dementia—which includes “early-onset” AD in those younger than 65 years—afflicted more than 5 million Americans ages 65 and older, two-thirds of whom were women.
In people under age 65, the most common form of dementia is frontotemporal dementia or degeneration (FTD)—the recent diagnosis for actor Bruce Willis. FTD affects parts of the brain controlling “executive functions” and can impair behavior involving judgment, empathy and foresight. As in Willis’s case, an early symptom of FTD can be progressive aphasia, the loss of ability to express or understand speech.
In patients with Lewy body dementia, balloon-like protein clumps in the brain, not unlike the protein causing the plaques and tangles of AD, can impair brain-cell functioning and cause unusual symptoms, such as acting out dreams while sleeping and visual hallucinations. Vascular dementia—once called “hardening of the arteries”—affects blood vessels and most often appears as slowed thinking and difficulties with problem solving. Another prominent type is “mixed dementia.”
Two new drugs, Lequembi and Aduhelm, made headlines in recent years for temporarily reducing cognitive decline and possibly slowing the progression of AD —the first hope for AD sufferers, in the absence of any treatment. Controversy swirls, however, around both drugs— monoclonal antibodies that target beta-amyloid protein–due to persistent uncertainty about the role of amyloid proteins in AD, which is most strongly linked to age and genetics. In addition, the drugs can produce minimal benefits and cause significant health problems, and each costs more than $25,000/year.
Also developed recently, the “early-detection” PreclivityAD blood test measures beta-amyloid proteins in the brain. Along with other variables including genetic analysis, the test assesses a patient’s amyloid probability score, indicating “the likelihood they had AD or were at risk of developing the disease.” The developer C2N Diagnostics has been testing an updated, better performing version that includes an additional AD marker: tau proteins that form tangles in the brain. Based on PET (positron emission tomography) scans, tau tangles are to date the best predictor of future brain atrophy.
(PET scans remain the gold standard for AD testing but cost $5,000 to $8,000 per scan; while another test analyzes levels of amyloid and tau protein in cerebrospinal fluid but requires a spinal tap and costs about $1,000. PreclivityAD costs about $500, is not yet covered by insurance and is slightly less accurate than the other two.)
With family history high on the list of AD risk factors, genetic testing can detect the APOE variants 2, 3 and 4—of which APOE4 can indicate the highest risk—though the association of any of these with AD remains unreliable. Alternatively, cognitive screening can help reveal early brain impairment, although a 2020 federal panel withheld its endorsement due to a dearth of research on benefits and harms. In addition, cognitive testing produces less accurate results for well-educated people—notably those who have scored high on academic tests—who engage in regular cognitive activities, such as reading, writing, teaching and learning a foreign language.
That chronological age can diverge from biological age has become a point of emphasis in recent evaluations of President Biden’s mental fitness. In people who are active, according to the New York Times, “the brain continues to evolve and some brain functions can even improve —a phenomenon experts called the neuroplasticity of aging.”
In the news just last week: Taking a daily multivitamin “might help slow memory loss in ages 60 and older,” based on results from a large nationwide study. According to the researchers, “Put another way, the multivitamin group was an estimated 3.1 years ‘younger’ in terms of their memory function than the placebo group.” This finding contradicts years of consensus that better bio-availability of crucial vitamins came from consuming them in food (compared with supplements)—especially from fresh fruits and vegetables—and was sufficient to slow cognitive decline associated with low levels of vitamins B1 (thiamine), B12 and D.
Similarly in the case of omega-3 fatty acids, past advice has emphasized consuming healthy foods, notably fatty fish and sardines. On the other hand, the larger quantities of these fats in fish-oil supplements may be more effective at increasing blood flow in areas of the brain concerned with memory and cognition, and clearly work better for people with particular health issues—such as dry eyes, if used alongside other treatments, such as artificial tears.
Risk factors most often linked to age-related impairment are those over which people are considered to have some control, including high blood pressure, high cholesterol and smoking. Also on the list but more challenging to control are traumatic brain injuries—for which falling down is the leading cause—along with diabetes, obesity and depression.
Inflammation is emerging as a primary culprit in most of these conditions—linked to “all known genetic and environmental risk factors for AD,” according to one summary report. As a result, keeping a lid on inflammation-inducing stress ranks high on the list of measures to help prevent or postpone dementia—as are anti-inflammatory medications and diets.
Generally, anti-inflammatory protocols (AIPs) emphasize eating a wide variety of fruits and vegetables, unsaturated fats, minimally refined whole grains, tea, coffee, herbs, spices and oily fish— and avoiding foods such as fatty cuts of red meat, refined sugary foods and beverages and excess alcohol. Sugar is a primary villain, with evidence that fructose provokes many of the brain changes associated with AD.
Topping the list of prescription drugs implicated in symptoms of dementia—for people who take them for longer than a few months—are benzodiazepines, along with anticholinergics that include medications for allergy, depression, high blood pressure and incontinence. While these drugs have side effects that include “confusion, clouded thinking and memory lapses,” studies have not yet proved that they cause dementia; in addition, many people rely on them for health benefits.
Among other difficult-to-control items on the do-not list are levels of noise and air pollution—along with back sleeping, though that may be risky only if linked to disordered sleep and trouble breathing at night.
For me, sugar remains the main dementia-related demon, but at least I can count the teaspoons. Social engagement, on the other hand, is trickier—requiring a balance of time spent with other people along with enough alone time to keep stress levels manageable.
—Mary Carpenter regularly reports on topical issues in health and medicine.
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My mom had dementia, and my sisters and I are obviously very interested in any research on preventing or slowing development of the disease. The deterioration of our mother’s intellect, which was formidable, was heartbreaking. The worst was in the early months, when she recognized that she couldn’t remember things. Looking back, and reading your column, has me recognizing symptoms we all missed. But will be able to perceive in ourselves.