[Editor's note: this is only a portion of the complete article]
A current book that is on the New York Times best seller list, Grain Brain: The Surprising Truth About Wheat, Carbs, and Sugar-Your Brain's Silent Killers, written by Neurologist Dr. David Perlmutter, asserts that a diet high in carbohydrates can actually be instrumental in the development of dementia. Perlmutter, who is a professor of Medicine at the University of Miami as well as a Fellow with the American College of Nutrition, has raised some important and interesting arguments in favor of this position. Yet, his arguments are far from airtight.
Perlmutter has pointed to the use of the A1C test that measures glycolated hemoglobin over a period of three to four months previous to the blood test. It provides an average blood sugar measurement. He does raise an interesting and important point. Often the test is used to measure the average metric of blood sugar over the past few months for many diabetics. However, it is really looking at more than that; it is looking at the glycation going on in the body, which ultimately leads to oxidative stress, free radical formation and inflammation. These are all harmful to the body and in particular, to the brain. He also points to recent studies that have shown an association between elevated levels of blood glucose and an increased probability for dementia. Furthermore, he states that even mild blood glucose increases, which can be in the high normal range, can still be detrimental and lead to glycation, inflammation and an increased likelihood for dementia. He states that too many physicians look at the blood glucose level and as long as it is within the normal laboratory parameters they feel comfortable with the results. However, he states that physicians should not be dismissive about these high normal results and should advocate lower blood glucose levels under 100. He states that regardless of the normal parameters, as they approach the high levels of the normal range, a person increases their probability for acquiring dementia. However, I am not sure how Dr. Perlmutter has determined this, or how much of a probabistic increase results if it does, and what is the mathematical means that he has used to determine this result?
Dr. Perlmutter does quote a number of studies that have found associations between higher carbohydrate dietary consumption and a higher risk for acquiring dementia. However, he further admits the shortcomings of many of these studies, which were observational. Therefore, although relationships were found between higher carbohydrate diets and the probability for acquiring dementia, this should not be interpreted as carbohydrates necessarily being causative. Without true experimental-based studies that are able to control for many of the confounding factors, too many possible variables could be influencing the relationships that have been witnessed in the studies cited by Perlmutter. Furthermore, the correlational studies, since they are not being held constant, all probably had quite different levels of what they viewed as higher carbohydrate levels. Therefore, how high is what is referred to as being too high as it relates to carbohydrate consumption? Where is the level of demarcation that quantifies a healthy level from a potentially harmful level? Finally, is there anything that he can quote and identify as an identifiable quantification that provides an empirical basis of support other than guesswork and an intellectual eyeballing of what he thinks in his clinical judgment are valid quantifiable parameters? The answers to these are far from clear and need greater empirical support.
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Recent research over the last few decades has paid increasing attention to aging at the molecular level. In particular, a genetic component called telomeres, has garnered much attention over the last few decades. Chromosomes are long strands of deoxyribonucleic acid or DNA. DNA is our molecular blueprint of who we are, being the genetic blueprint for forming our genome. Telomeres are found at the end of the chromosome, looking like a cap that helps prevent other chromosomes from fusing together. In essence, a telomere is a part of the DNA found in the nucleus of the cell, made up of six repeating nucleotide bases-- thymine (T), adenine (A), and cytosine (C), or a TTAGGG sequence. Under normal conditions, when cells divide, telomeres and their repeating nucleotide sequence shorten with each cell division. Therefore, similar to determining a tree's age by cutting the tree and examining the number of rings that exist, examining telomere length on the molecular level can provide an indication of the age of the person.
As cells continue to shorten, the cell and ultimately the human being age, a process referred to as senescence. If the telomere shortens too much, the DNA can be damaged. Furthermore, as the telomere shortens to very short lengths, cell division ultimately stops. Certain cells need to naturally die off for proper health. However as individuals age, all of their body cells' genetic material are ultimately undergoing a telomeric reduction. Conversely, with cancer, the reverse is often witnessed. Certain cells in the body do not die off naturally and continue an unending life cycle due to enzymatic telomerase production and a tumor-type agglutination of unhealthy cells.
Given the information that has been presented so far, it appears that aging is an inevitable feature that is determined by the molecular structure of our genetic blueprint. Furthermore, although truth for this proposition appears to be found in what has come to be referred to as the Hayflict Phenomenon, which is the programmed capacity for cells to divide, even under optimal conditions, no more than approximately 50 to 60 times, setting a genetic upper limit to our lifespan, this does not mean human beings have no control in how long they can live. In fact, recent information has provided important knowledge on how we may ultimately slow aging down through the perseveration of telomere integrity.
A recent study that was led by Dean Ornish, Professor of Medicine as the University of California, San Franciso followed 35 men over five years. All 35 men had been diagnosed with low-risk prostate cancer. Of the 35 men, 10 of the men in the study were assigned to engage in a healthy lifestyle that was composed of a vegetarian diet, regular exercise and regular sessions of stress reduction through use of meditation and yoga. This served as the experimental group. The other individuals who did not experience lifestyle changes served as controls.
The study demonstrated some interesting results. Until recently most have assumed that the telomeric shortening was ultimately inevitable with aging, give or take some level of individual variation in the speed or progression of the shortening of the telomere, leading to individual differences in how fast one ages. However, in the Ornish study, at the end of five years, the researchers found that those that adopted the healthier lifestyle habits mentioned above demonstrated a younger looking DNA in terms of the degree of its shortening (Raffensperger, 2013). Not only was telomere shortening slowed, but it was actually reversed. In the 10 men who made lifestyle changes, telomere length grew by an average of 10 percent over the five year study period. Moreover, the quantitatively greater number of healthier lifestyle changes made was associated with more telomere growth. Conversely, the control group experienced a three percent reduction, or shortening in telomere length over the five year length of the study. The study results do have to be interpreted cautiously since the study was far from representative, quite small, with a fairly loose level of control. Yet, they do present some very interesting results that need further investigation, results that are quite inspiring and salubrious to say the least.
Telomere shortening is also related with many diseases. However, whether the diseases are caused by the shortening of the telomere or the telomere shortening causes the disease needs to be further studied. Furthermore, centenarians were found to have longer telomeres than those who were 85 years of age. Here again the question is whether the longer telomere led to centenarians reaching their status or was it due to their health being better, leading to greater telomere length, and subsequently greater age (Knox, 2013). Nevertheless, there does appear to be a connection between telomere length, disease and aging.
Overall however, there is increasing evidence that exercise, better nutrition, and subsequently enhanced health leads to a reduction in the rate of telomere degradation. Both younger and other marathon runners and track athletes demonstrated upregulation of telomere-stabilizing proteins. They also demonstrated decreased expression of apoptosis regulators. Both of these features were not found in more sedentary controls.
Both younger track-and-field athletes and the older runners had up-regulation of telomere-stabilizing proteins and decreased expression of vascular apoptosis regulators in circulating leukocytes compared with individuals who did not exercise frequently. Furthermore, other research has found that subjects who spent more than three hours each week in vigorous physical activity had longer telomere length as compared to subjects who were 10 years younger than them and who exercised less than 16 minutes each week (Giuliano, 2010). Even with mice that were subjected to increased exercise levels in the laboratory as compared to those that were sedentary controls, telomere length was enhanced among the more active mice (WebMD).
Genetics may also be susceptible to the anti-aging effects of exercise. One would anticipate that identical twins, given that they share the same genetic information, would be an ideal group to see if exercise has a telomeric-enhancing effect that could trump genetic blueprint they are born with and is part of their DNA. What in fact was found is that when one twin was active and one was sedentary and telomere lengths were compared, the identical twin with the greater activity had longer telomeres. This is quite compelling since identical twins share exactly the same genetic material.
Given what has been reviewed in this article, it appears that we are not just prisoners of our biology. It has been known for some time that exercise, healthy diets and healthy lifestyles can enhance our health and possibly even our longevity. However, now we are seeing increasing evidence for the health-enhancing effects of exercise and nutrition on the molecular level. It appears that exercise, a healthy diet, and a healthy overall lifestyle may have an epigenetic effect on our telomeres that exogenously can have a very beneficial impact on our immanent genetic profile, and potentially on our health and longevity.
Giuliano, V. (2010/Jan). Exercise, telomerase and telomeres. http://www.anti-agingfirewalls.com/2010/01/14/exercise-telomerase-and-telomeres/
Knox, R. (2013/Sept). Healthful Living May Lengthen Telomeres And Lifespans. http://www.npr.org/blogs/health/2013/09/17/223386084/healthful-living-may-lengthen-telomeres-and-lifespans
Neale, T. (2009/Nov). Exercise May Slow Telomere Shortening, Aging. http://www.medpagetoday.com/PrimaryCare/ExerciseFitness/17221
Raffensperger, L. (2013/Sept). Healthy Diet and Exercise Can Reverse Aging in Our Cells. http://blogs.discovermagazine.com/d-brief/2013/09/17/healthy-diet-and-exercise-can-reverse-aging-in-our-cells/
WebMD. Molecular Proof: Exercise Keeps You Young
Intense Activity Keeps Telomeres Long. http://www.webmd.com/fitness-exercise/news/20091201/molecular-proof-exercise-keeps-you-young
A recent editorial in the Annals of Internal Medicine has provided considerable debate about whether multivitamin use has any efficacy. The editorial titled, "Enough is Enough: Stop Wasting Money on Vitamin and Mineral Supplements," avers, in a very definitive manner, that using multivitamins is useless, providing no help in aiding one's health. The editorial goes on to state, "we believe that the case is closed - supplementing the diet of well-nourished adults with (most) mineral or vitamin supplements has no clear benefit and might even be harmful. These vitamins should not be used for chronic disease prevention. Enough is enough." The exclamatory and definitive nature of this editorial statement, however, leaves some room for pause.
Before one closes the case on the issue of multivitamins, a few things need to be addressed. The first contention that needs to be addressed is use of multivitamins for fighting disease. Whether multivitamins do or do not aid in preventing certain diseases is probably not fully closed since some studies have previously found that multivitamin usage does assist in maintaining health, especially among the elderly. Although they probably will not ward off chronic health issues that result from smoking, being overweight, failing to get adequate exercise, drinking heavily, eating poorly, or engaging in a myriad of other counterproductive health behaviors, the intent of multivitamin usage was never meant to override these types of issues. However, yes, it is true that many individuals attempt to delude themselves into thinking that using vitamins, or for that matter any type of pill, will lead to an easy and salubrious form of health-based intervention.
The next issue that needs to be addressed is the benefits derived from taking a multivitamin among those that eat well. Here again, the studies that were reviewed as the basis of the editorial are probably correct in stating that those who eat well and have well-balanced and nutritious dietary habits will receive little, if any, additional benefits from a multivitamin. However, many older adults fail to have proper dietary intake, and subsequently many fail to take in the necessary level of many vitamins and minerals to maintain proper health. This is often found among many older adults who live alone.
Also quite surprising is how the statement was framed and presented, especially to a professional audience. The Annuls is a respected journal and it therefore is more surprising that even in the editorial section, it would allow such a potentially problematic, misleading and for the most part, unscientific statement to be rendered to the public, and in particular, professional audience that makes up most of its readers. Within the realm of science, claims that often attempt to make broad generalization in a definitive manner are often quite problematic. The editorial in the Annuls provides a broad and definitive statement and their wording is quite misleading by stating that the "case is closed" on the use of multivitamins. It extrapolates from three studies, using the results of these three studies to apply to all individuals. Stating that "enough is enough" and the "case is closed" are words that often are not used in science, and the unscientific word usage that the author of the editorial uses indicates a level of hubris and bias that can mislead the public.
As mentioned, the editorial is based on the results of three studies. Even when a meta-analysis is done on previous studies, the minimum to justify their results often is well beyond three studies. Also, the studies often have to have some level of similarity. In this case one study is based on results of 450,000 individuals (an impressive number to say the least, but the number of individuals by themselves do not lend credence to the soundness of the study), and the effects that multivitamin use had on health, cancer and mortality. Another study tracked 6,000 men, who were all physicians, over a period of 12 years, to see if multivitamins had any effect on cognitive decline. The use of just men and physicians is far from being a representative study. Finally, the third study, also quite different than the previous two mentioned, looked at 1,700 men and women, only this time it looked at the effects of multivitamin usage on those that were recovering from heart attacks, and whether using a multivitamin prevented a second heart attack. These three studies failed to demonstrate any level of efficacy for multivitamin usage. These three studies are the basis by which the editorial extrapolated its results and justifications for the definitive stance that it took toward multivitamin use.
It must also be stated that this article is not saying that the statements in the Annuals' editorial is incorrect. However, the statements made were definitely cursory and excessively brazen. Furthermore, making such a definitive statement based on three studies, which all are looking at something different on a health and medical level, does not provide adequate justification for such a commentary. Therefore, whether the editorial's statement is correct or not will depend on much more scientific investigation. Science is a continuous enterprise. Typically, nothing is ever closed since our reality is far from invariant. Therefore, saying that one is closing discussion and any further investigation based on the paucity of investigative results used to justify the statements made in the editorial is troublesome.
As has already been mentioned, making a blanket statement as was made in the editorial usually fails to truthfully cover reality. Furthermore, as previously mentioned, many older adults do suffer from nutritional deficiencies that may ultimately benefit from vitamin supplementation. Although holding grand delusional thoughts about vitamin supplementation negating poor lifestyle or health behaviors or reversing chronic forms of illness is also a problem found in our society, this is a different issue that is a separate problem. However, making exclusionary statements regarding multiple vitamins is also quite injudicious. As with most things in life issues of high variability often preclude the use of either/or reasoning, an error that was made by the Annuals' editorial, which can mislead and ultimately result in harmful ramifications.
Jaslow R. Multivitamin researchers say "case is closed" after studies find no health benefits. http://www.cbsnews.com/news/multivitamin-researchers-say-case-is-closed-supplements-dont-boost-health/
Neergaard L. Two new studies debunk benefits of multivitamins. http://www.nbcnews.com/health/two-new-studies-debunk-benefits-multivitamins-2D11757314
Walton AG. Vitamins lack clear health benefits, may pose risks. http://www.forbes.com/sites/alicegwalton/2013/12/17/study-multivitamins-lack-clear-health-benefits-may-pose-risks/
Cognitive decline as one gets older is often something that is feared by many. There are many reasons for cognitive decline, and although many associate it with age, for the most part age in isolation is usually not the only reason for cognitive decline. Furthermore, cognitive decline is not inevitable as one gets older. However, some new research has found that some pathogenic agents that have often been associated with causing diseases in other parts of the body can also influence cognition as well.
One microorganism that has been implicated is the herpes simplex type 1 virus. Research published in the journal, Neurology, examined 1,625 people who were on average 69 years of age. Memory and blood tests were taken at eight year intervals. The researchers found that those with higher levels of the herpes simplex type 1 virus in their blood were more likely to have more cognitive deficits. The herpes simplex type 1 virus is the virus that is often associated with cold sores. It should not be confused with genital herpes, or herpes simplex type II.
More research needs to be done before one can be more definitive about the relationship between the virus and cognitive decline. As was mentioned, the study found a relationship or association between the herpes virus and cognitive decline, but again the association does not indicate causation. There are too many variables that were not controlled for in this study.
In line with the above study, other studies have found the Helicobacter Pylori (H. pylori), a bacterium linked to many ulcers found in the gastrointestinal tract, may also be instrumental in mood problems and cognitive impairment. It has been known for some time that the gastrointestinal tract is linked to the brain. In fact, we also have what is known as an enteric nervous system, a special nervous system for our gastrointestinal tract, which works in association and complements our autonomic and central nervous system.
In what has been referred to a "leaky gut" disease, pathogenic agents such as H. pylori can leak out of the stomach region and impact the brain. Normally the stomach is a well-contained organ that prevents any type of leakage; however individuals can have their gastrointestinal mucosa compromised leading to the leakage out of pathogenic microorganisms. H. pylori has been found to be associated with increased depressive disorders and cognitive impairment. Again, these studies are far from being definitive.
It must also be mentioned that as individuals age, intestinal mucosa often thins considerably. When this happens, gut leakage can happen. If microorganisms are found to be truly implicated in mood and cognitive disorders, becoming more sensitive toward conducting tests for microorganisms found in the blood that may be instrumental in causing cognitive decline and depression may have to be done more readily during the examination process.
The good news about these finding is that they are highly correctable. Although many people suffer from many forms of intractable depressive disorders as well as cognitive decline that cannot be reversed, depression and cognitive decline that may be associated with these forms of infectious agents could be addressed through highly efficacious pharmacological interventions. Especially with the bacterial infection like H. pylori, a treatment regimen of antibiotics and proton pump inhibitor agents often can eradicate the intestinal microorganism that is not only causing distress within the gastrointestinal tract, but also influencing the neurological system as well.
Given this information, one may want to think how their stomach can not only influence their gastrointestinal health, but also be mindful on how their stomach and gastrointestinal tract can dramatically impact our cognitive health. Understanding that the enteric system with its own enteric nervous system is intricately aligned with our other nervous systems can help us understand how our stomach may influence our brain, our thinking and our mood.
Bakalar N. Infections tied to cognitive decline. http://well.blogs.nytimes.com/2013/03/29/infections-tied-to-cognitive-decline/?_r=0
Jaslow R. Herpes virus may lead to memory loss, cognitive declines. http://www.cbsnews.com/news/herpes-viruses-may-lead-to-memory-loss-cognitive-declines/
Rodriguez T. Gut bacteria may exacerbate depression: Microbes that escape the digestive tract may alter mood. Scientific American. http://www.scientificamerican.com/article.cfm?id=gut-bacteria-may-exacerbate-depress
The Longevity Project was a longitudinal study started by Stanford University Psychologist Lewis Terman in 1921. Terman's study initially looked at issues of intellect. The 1,500 subjects were tracked over eight decades. From this initial study some important information was revealed about longevity, including what was instrumental in helping some age well, and what also failed to enhance longevity and healthy, functional aging.
A common thought has been that marriage will guarantee greater longevity (Friedman & Martin). This is a partial truth. To say marriage in itself enhances longevity for all, and therefore acts as a constant without any variation among men and women is incorrect. Marriage apparently benefits men more than women. In fact, divorce also appears to have disparate impact on men, severely curtailing men's longevity. However, for women, the benefits that marriage held among those who participated in the Terman study appeared negligible. Married women did show some mild enhancement in longevity, but overall, marriage was not a statistically significant variable for enhancing longevity among women. Furthermore, women who experienced divorce and did not remarry also did not necessarily suffer severe reductions in longevity as was found to exist among men.
Another common thought is that taking it easy and disengaging from active involvement in society can enhance longevity. However, the Terman study participants who experienced the most career success and had the greatest productivity also had greater longevity (Friedman & Martin). Furthermore, those who continued to remain productive and actively engaged were more likely to live longer lives. This is not to say that enhanced stress is good for someone. However, what may be happening is that a continued level of productivity helps the person remain physically and mentally active and provides them with a sense of purpose. Remaining active and productive may also moderate many of the deleterious stressors that may actually lead to reduced longevity.
Conversely, being detail-oriented, obsessive and worrying about small details has been thought to be traits that could shorten one's life expectancy. However, one of the most consistent findings among those in the Terman study was that having higher levels of conscientiousness led to greater longevity (Friedman & Martin). The study found that the best predictor of longevity in children was having higher levels of conscientiousness and this continued to remain a firm predictor into adulthood. Thrifty, detailed-oriented, and meticulously planning individuals lived the longest among the participants in the Terman study. Apparently, as long as individuals do not engage in a pathological level of stressfully conscientious behavior, being meticulous, punctilious and mildly of the so-called Type A personality variation may be quite enhancing for one's longevity.
A higher level of education has been thought in itself to enhance the probability for greater longevity. However, as an isolated variable, it was not found to be a highly important predictor of longevity (Friedman & Martin). This is not to say that education is irrelevant for longevity. Much more relevant than the number of years of formal education was what has already been mentioned: the level of productivity as well as facing appropriate levels of challenges with a level of efficacy and resiliency. Education could well enhance this given that those with greater education also have more productive and challenging types of work in their daily lives.
Another myth often associated with longevity is that those who are more social and extroverted live longer. However, research has not found this to be necessarily true. In fact, those who were more extroverted did not have any significant differences in their longevity as compared to those who were more introverted. Consider that who are more social and extroverted may also engage in unproductive behaviors such as drinking and smoking that may reduce one's longevity.
Optimism is often touted as a sure-fire characteristic that enhances one's longevity. However, cheerful, optimistic children were actually less likely to live to an older age than their counterparts who were less optimistic and cheerful (Friedman & Martin). Moreover, excessively optimistic individuals who fail to worry about much may actually fail to give credence to signs that may portend potentially important indicators of illness or other forms of deleterious issues.
Exercise is one of the most important lifestyle factors for enhancing longevity. However, just because one is athletic when one is younger does not necessarily mean this confers greater longevity. In fact, those who are very active in youth and fail to stay active in middle and later adulthood, thereby increasing their sedentary lifestyles, nullify any benefits incurred through early life activity. It is important to stay active throughout one's life. Furthermore, one does not have to run long distances, lift heavy weights, or be a gym rat to incur benefits from exercise. An individual who engages in even mild activities like walking daily, gardening, cutting grass, and attempting to limit their amount of sedentary lifestyle can increase longevity.
Many myths and misconceptions related to aging and longevity continue to exist. Although this post has attempted to succinctly address some of the more common ones, this list is far from exhaustive. Nevertheless, this author has attempted to address and refute some of the more common myths that continue to be stated in relation to longevity. That being stated, these findings are based on evidence up to this point in time, so one must view the research tentatively. Furthermore, one must also be careful in interpreting some of the results in binary, either-or, fashion. For instance, just because optimism by itself was not found to be an important predictor of longevity, that does not mean one should look at this in a Janus-faced fashion and become the ultimate pessimist. Furthermore, many things have to be examined in context. Although education, in exclusivity, was not found to be a significant predictor of longevity, education as it relates to other contextual features associated with greater levels of education can, and often do, have important implications for longevity.
Subsequently, research on longevity continues to be in its infancy. There are many more myths that need to be dispelled. Furthermore, there is a need to disseminate the inaccuracies to the public, including a continued need for more accurate information among professionals who work with, and service, the older adult population. As we continue to make greater strides in research on aging more myths and misconceptions will be addressed and corrected as they relate to the myriad of anecdotal types of information that are often associated with what has often come to be termed the "anti-aging industry."
Friedman HS & Martin LR. The myths of living longer. In Aging-Annual Editions 13/14, Harold Cox (Ed). 2011; pp. 30-31. McGraw-Hill, New York, NY.
During the 2013 meeting of the American Psychiatric Association, the renowned neurologist, Gary Small, MD, addressed whether a change in one's lifestyle can aid in the prevention of Alzheimer's disease. Although research continues to look for a cure, there currently is no form of treatment that can cure the more than 5 million individuals in the U.S. with the disease. At best, we have a few medications that may slow the disease progression, and in some, these medications may not work at all and even lead to serious side effects.
There is compelling evidence that certain genes play a significant role in this disease. Small pointed out that some of these genes actually enhance an inflammatory response that may lead to the progression of Alzheimer's disease. However, he claimed we are not necessarily prisoners of our genes, and that behaviors such as exercise, nutrition and proper sleep habits can act as anti-inflammatory mechanisms that enhance our brain health.
Physical exercise appears to have the greatest scientific support for helping to prevent Alzheimer's disease. It appears to work by reducing the inflammatory index in the brain and reducing the biomarkers indicative of Alzheimer's disease. Small noted that even as little as 15 minutes of walking each day has been found to demonstrate an appreciable preventive effect of Alzheimer's disease. Small also addressed the issue of enhanced mental stimulation, such as through learning or doing challenging mental tasks. This has been a very common area that has been touted as being important for prevention in the area of dementia as one grows older.
Small also addressed stress as an issue that could potentially accentuate the development of Alzheimer's disease. It is imperative that as individuals age, learning how to relax can be critical in fostering enhanced brain health. Getting a proper quantity and quality of sleep is important to augment relaxation as well as enhancing brain health.
Nutritional intake, especially increasing anti-oxidant fruit and vegetable intake, coupled with increased omega-3 fatty acid, has been found to hold strong preventive features toward enhancing health and warding off inflammation.
Click here to read a full-length article to learn more about preventing Alzheimer's disease.
The fear of cognitive debilitation as we age is one of the greatest apprehensions that individuals have about aging. It is also an area of misconception as well. Although dementia and other forms of major cognitive decline are not inevitable as we age as so many think, aging is correlated with greater levels of cognitive debilitation, especially through various forms of dementia. Furthermore, as a larger number of our population reaches older age, more concern has continued to exist on how one may be able to ward off feared neurocognitive disturbances such as Alzheimer's disease. The following are some suggestions that have been made by a number of experts in the field of aging and neuroscience.
The first, and possibly the most important source of enhancing brain health, is to remain physically active, especially through regular exercise. Higher rates of physical exercise can have a pronounced effect on reducing dementia. However, even smaller amounts of exercise, as little as 15 minutes three days each week, can have an appreciable effect on enhancing brain health (Howard, 2012).
Another recommendation has been to engage in resistance exercise through the use of weights or even resistance training through exercise bands or calisthenics. In addition to helping to maintain bone and muscle health as we age, it is thought that resistance training helps to promote insulin-like growth factors to nourish and protect brain cells (Howard, 2012).
A third important tip for brain health is to seek out new skills. This is basically tantamount to learning a new and challenging skill. The emphasis on new and challenging is important since it helps to ramp up metabolic activity in the brain and increase brain cell connections. If a person continues to do things that they are already facile at it fails to provide the neurological fodder for building new brain connections. Do not fall prey to the adage of "old dogs cannot learn new tricks." Although learning may not come as easy as when one was younger, attempt to learn new and challenging things to enhance the connectivity of the brain.
The fourth recommendation is to reduce stress. Stress enhances cortisol levels, an important stress hormone, and unremitting cortisol flooding the brain is neurotoxic, which can lead to cell death in the brain. Subsequently, engaging is various forms and techniques of relaxation, such as through meditation, yoga, or other forms of tension reduction strategies can be very important to one's overall brain health.
One's diet is important. Eating a diet that has higher levels of important fatty acids and antioxidants, such as those found in certain fish, nuts, fruits and vegetables can provide a considerable benefit to long-term brain health. Columbia University found that eating a Mediterranean diet reduced the risk of Alzheimer's disease by 34%-48% (Howard, 2012).
Another area that has been given greater attention is possibly using certain spices that may have a potentially therapeutic effect on the brain. Spices like black pepper, cinnamon, oregano, basil, parsley, ginger, and vanilla are high in antioxidants. In addition, the ingredient curcumin found in turmeric, which is a common ingredient in many Indian curries, might hold considerable potential. In looking at the effect of curcumin in animal research, scientists have found that it reduces amyloid plaques, the plaques that play a considerable role in Alzheimer's disease, as well as also helping to reduce tissue inflammation in the brain (Howard, 2012).
Another tip for brain health that researchers provide is developing a unified sense of purpose in one's life. Researchers have found that those that have a greater purpose with a greater clarity in their goals had reduced levels of Alzheimer's disease.
Developing a strong social life may be a protective buffer in helping to prevent dementia. Being socially engaged and interactive has been found to be very instrumental in enhancing one's health at all levels, and as it relates to brain health, it continues to show important health enhancing effects.
Remaining healthy in other areas helps to promote brain health. Reducing levels of obesity and maintaining a healthy weight, maintaining a healthy blood pressure, and keeping one's blood glucose levels under control are all significant in warding off cardiovascular disease, kidney disease as well as many other forms of physical illnesses, all of which can further increase the likelihood for impairing one's brain health.
Finally, make sure you are mindful of maintaining proper vitamin intake. Most of this can be done through a well-balanced diet, but as we age, one may suffer from vitamin deficiencies due to impaired digestive absorption from food intake. Physicians also have to make sure they are more aware of examining deficiencies in this area that could lead to possible cognitive declines.
Although many individuals think that cognitive decline is an inevitable part of aging, this is not true. Many things can be done to reduce and even prevent cognitive decline. However, as with anything in life, a level of effort is needed to achieve the desired goals. However, getting into a regular habit can provide benefits that lead to individuals achieving a much more functional life.
Howard B. Age-proof your brain: 10 easy ways to stay sharp forever. AARP The Magazine. 2012, Feb/Mar, p. 53-54, 56.
It has been known for some time that the pharmacokinetic features of many medications are quite different based on the age of the person. In particular, many medications that could be given to younger adults with no issues can often lead to adverse affects when given to older adults. Furthermore, the same dosage of a medication that is therapeutically effective for a younger adult may be excessive or build up to dangerous levels in older adults. Also, there are some medications that could be viewed as totally appropriate for the younger adult, yet given to older adults with the same condition, these same medications may be totally inappropriate.
This level of wisdom regarding medications and age has been firmly consolidated among the medical community when it relates to prescribing therapeutic agents for adults and children. However, for some reason, as it relates to younger and middle-age adults versus older adults, the prescriptive and proscriptive logic for pharmacological intervention is at times clouded or even lost. A recent study in the Journal of the American Geriatrics Society continues to find inappropriate medications being prescribed for older adults. Furthermore, the study found that many of these medications are posing an imminent risk for many of our society's older adults.
The current study examined individuals admitted to the ICU unit and followed these individuals after they were discharged. Adverse occurrences due to medications are the most common problem that many older adults face after hospital discharge. This problem may possibly be getting worse as evidenced by the 96 percent increase in medication-related hospital admissions among those who were 65 to 84 years of age between 1997 to 2008 (Morandi et al., 2013). Moreover, almost one-half of these admissions for adverse medication occurrences occurred among those who were 80 years of age or older (Morandi, et al., 2013). Therefore, given this data, it provides fodder for the current study that followed hospitalized older adults and the pharmacological interventions that they encountered as part of their treatment intervention.
The study was a prospective-based study that examined individuals admitted to the intensive care unit. The study had 135 patients that were enrolled and followed in the study. The average age of the participants in the study were 68 years of age. The individuals were followed during their hospitalization and after their discharge.
The study was interested in tracking and investigating those that were discharged on potentially inappropriate medications (PIM) and actually inappropriate medications (AIM). Drugs that are classified as PIMs are those that can have a potentially detrimental effect for the elderly patient. However, PIMs are not necessarily in-and-of-themselves exclusively detrimental and may have benefits that outweigh their costs in certain therapeutic situations. However, drugs classified as AIMs are viewed as having costs that outweigh any potential therapeutic benefits for the older adult. The elderly have been a growing portion of ICU occupancy and many of these types of medications are first prescribed to the elderly within the intensive care unit. Furthermore, it has been found that 85 percent of the elderly who are discharged from the hospital ICU were prescribed at least one PIM and 51 percent were prescribed at least one AIM upon discharge (Morandi, 2013). It was also found that 50 percent of the PIMs and 59 percent of AIMs were first prescribed while the older adult patient was in the intensive care unit (Morandi, 2013).
Results of the Study
The study found that of the 250 PIMs prescribed to the discharged elderly, the most common types where opioids (28 percent), anticholinergics (24 percent), antidepressants (12 percent), and drugs potentially causing orthostatic hypertension (8 percent). As mentioned, although the PIMs have the potential for causing harm, the study found that most of the time the therapeutic intervention with PIMs had benefits that exceeded any potential for harm. Conversely, in examining the patient cases where drugs classified as AIMs were prescribed, anticholinergics were the most commonly prescribed actually inappropriate medications (AIMs) at 37 percent. Other drugs that were viewed as actually inappropriate medications prescribed upon discharge were nonbenzodiazepine hypnotics (14 percent), and opioids (12 percent). The study found that 36 percent of the elderly discharged on medications that were classified as PIMs, also were classified as actually inappropriate medications (AIMs). The medications classes with the highest representation with the AIM category prescribed to the elderly were anticholinergics (55 percent were actually inappropriate medications), atypical antipsychotics (71 percent were actually inappropriate medications), nonbenzodiazapine hypnotics and benzodiazapines (67 percent were actually inappropriate medications) and muscle relaxants (100 percent were actually inappropriate medications).
In this study, medications labeled as potentially inappropriate medications (PIMs) were frequently prescribed to many elderly within the intensive care unit and remained as part of their treatment regime even after leaving the hospital. However, after clinical review, most of the PIMs were often viewed as clinically appropriate. However, most of the PIMs did not meet the criteria for being actually inappropriate medications. The authors of the study state that greater focus should be placed on avoiding the use of actually inappropriate medications and less emphasis should be given to those with the PIM classification.
Although the study did find that many of those medications listed as potentially inappropriate medications were being prescribed with appropriate clinical justification, the study also did find that there was nevertheless a clinically significant amount of medications that were documented as being actually inappropriate medications, which were being prescribed to many older adults. It appears that many older adults are still being prescribed medications that have a strongly adverse profile, especially given their age group and greater pharmacological sensitivities that often encompass advancing age. As mentioned at the beginning of this paper, hospital admissions among older adults have been increasing due to adverse medication complications. Although not all of these hospitalizations are due to physician-prescribed medications, physicians may need to become more sensitive to their iatrogenic contributions to this problem.
Morandi, A. et al., (2013). Inappropriate Medication Prescriptions in Elderly Adults Surviving an Intensive Care Unit Hospitalization. Journal of American Geriatric Society, 61(7):L 1128-1134.
A recent study out of France has examined the impact of retirement and the probability of developing dementia. There have been few studies that have examined the relationship between retirement and dementia, but this study demonstrated an impressive and statistically significant relationship between these two variables. The study's findings demonstrated that retiring later in life significantly reduced the likelihood of a person developing dementia. Dr. Carole Dufouil who led the study stated that the findings demonstrate the "importance of maintaining high levels of cognitive and social stimulation throughout work and retiree life."
The study found that those who retired at 65 years of age had a 14.6% lower risk of developing dementia than those who retired at 60 years of age. This reduced risk, holding all other things constant, what statistically significant at P < 0.0001. This result demonstrates the highly statistically significant results found to exist for those that retired later than earlier in life.
The study is being viewed as further evidence for maintaining intellectually and cognitively engaged. The so-called "use it or lose it" principle appear to be at play here. The assumption found in this study is that those that maintain more years of work also maintain greater cognitive activity that could be beneficial for warding off cognitive decline. Therefore, work in itself is not the key, but work as a method of maintaining a level of cognitive stimulation is what is important. Subsequently, it can also be assumed that many individuals who retire concomitantly fail to maintain adequate levels of cognitive stimulation. If individuals use retirement as a source of complete disengagement, this may hasten cognitive decline. Therefore, if one's work is their only source of cognitive stimulation, a person may want to rethink about retiring early since it may hold formidable consequences for their cognitive health.
The Joy of Old Age (No Kidding) is a very inspiring editorial written in the New York Times by the well-known and world renown neurologist Oliver Sacks. Sacks describes his life, as well as his thoughts, about his approaching 80th birthday. Far from feeling a sense of despair, he explains that he welcomes his approaching birthday and is looking forward to having achieved such a milestone. Sacks is still practicing, still teaching, and still writing. He continues to feel compelled to make contributions and not sit or foster a level of complacency. In this editorial, I personally was struck by how Sacks has adjusted to his later stage of life. He does not attempt to sugar-coat his 80 years of life and he does mention that he has some regrets as stated,
I am sorry I have wasted (and still waste) so much time; I am sorry to be as agonizingly shy at 80 as I was at 20; I am sorry I speak no languages but my mother tongue and that I have not traveled or experienced other cultures as widely as I should have.
In his own inimitable way, he provides an incisive editorial that begs to be read. Even as Sacks is approaching his 80th birthday, one cannot help but feel his excitement that he exudes as he approaches the end of his life, yet views each day enthusiastically and energetically as a new beginning. As he states: "Eighty! I can hardly believe it. I often feel that life is about to begin, only to realize that it is almost over." One has to think, that even as Sacks is in the winter season of his life, that season still will be a long and productive one.
Some recent research has produced some very interesting results regarding yoga and memory. It was found that a 20-minute session of Hatha yoga significantly improved the cognitive abilities of the participants of the study, especially related to working memory and inhibitory cognitive functions. Although most of the participants in the study were younger, similar results have been found using older adults. The study was led by Neha Gothe, professor of kinesiology, health and sports studies at Wayne State University and its findings were reported in the Journal of Physical Activity and Health.
The Yoga participants engaged in a 20-minute progression of seated, standing and supine yoga postures. While in these different yoga postures, the participants used various isometric muscle contraction and relaxation techniques as well as regulated deep breathing techniques. The participants also completed an aerobic treadmill workout, since in previous studies aerobic exercise has been shown to enhance memory and cognitive performance.
Gothe and her colleagues were surprised to find that the participants who engaged in yoga showed marked improvement in reaction time and accuracy on cognitive skills tests that were superior to those effects found when compared to the aerobic exercise condition. In fact, the aerobic exercise condition failed to demonstrate any significant improvements in working memory or inhibitory control on their cognitive skills tests.
The effects found from meditation may actually result from the reduction in anxiety and stress that often is found to exist among those that engage in yoga, especially brought about through systematic muscle relaxation and deep breathing. Yoga also teaches more focus on body movements, leading to a greater level of body-mind awareness while blocking out many of the distractions that often lead to stress and anxiety in our daily lives.
Yoga often makes use of controlled systematic movements, having the person provide attention to their body movements and sensations, while blocking out many of the other distractions that often impinge on our conscious lives. Moreover, using breathing and muscle relaxation helps to provide a complete body relaxation response. Yoga also provides effective techniques for helping to strengthen muscle tone, enhance flexibility, and exercise one's brain mechanisms that help to enhance balance.
Although yoga looks deceptively simple, it is a skill that often takes considerable practice to achieve successful results. This could be problematic for many older adults who may not want to enter into a type of health modality that takes some time to learn and be successful at, especially to achieve the desired beneficial health-enhancing results that were found among the participants in the study.
Nevertheless, yoga does appear to have many salubrious effects. Given its ability to help assist with overall relaxation and reduce stress levels -- both of which if not regulated have been found to lead to a greater probability of illness and accelerated aging -- it would behoove individuals to learn and practice yoga and even various forms of deep breathing and systematic muscle relaxation on a daily basis. In fact, starting off with short 5 to 10-minute sessions a couple of times daily, gradually increasing in the time spent using these techniques throughout the day may be the best way to learn and eventually become proficient at using these important health-enhancing skills.
Yoga combines breathing and muscle relaxation with body movements and an enhanced attentional focus. Many who practice yoga say that the attention they have given to their body movements leaves them feeling mentally relaxed. This type of enhanced attentional focus could often be beneficial toward helping many older adults deal with issues such as pain (both physical and emotional), anxiety and depression. However, here again, achieving the attentional focus that is often needed for efficacious results is often something that takes practice in achieving. Therefore, again practice is needed.
The overall results from this and other studies have demonstrated favorable results toward health enhancement. However, yoga techniques are skills in themselves that have to be learned. Many people frequently make the incorrect assumption that achieving a state of relaxation or an enhanced level of healthful consciousness can be achieved be sitting around the house or lying down and taking a nap.
As with anything in life, to achieve optimal benefits, a level of work must be done to correctly learn how to achieve the 1) level of attentional focus one needs to optimize the yoga response; 2) be able to correctly breathe in a manner that facilitates relaxation; 3) learn how to systematically engage is isometric muscle tensing and relaxation to achieve proper muscle relaxation; and 4) be able to become sensitive to the kinesthetic and proprioceptive abilities that we often fail to pay attention to, yet provide important feedback information about our body and its level of tension and relaxation.
Therefore, instead of thinking of yoga as something that people in other countries do, help older adults open up their minds by toward gradually introducing yoga, or some of the methods that yoga uses, to help enhance their total level of health and fitness. Although it does take practice, the benefits that can be achieved from learning this important technique are worth the time and effort.
Reference: Science Daily (2013, June 5). A 20-minute bout of yoga stimulates brain function immediately after. http://www.sciencedaily.com/releases/2013/06/130605190552
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Acetylcholine is an important neurotransmitter found in the brain. In fact, reduced amounts of this neurotransmitter have been found to exist in the brain of those that suffer from Alzheimer's disease. Acetylcholine is an important neurotransmitter that plays a significant role in memory, as well as innervation of muscle activity. Anticholinergic agents counter the effects of acetylcholine and block this important neurotransmitter. As was mentioned this can potentially cause adverse effects on memory since it is an important agent for memory.
Older adults can be especially sensitive to medications that fall into the anticholinergic classification. Furthermore, many medications, both prescription and over-the-counter, have anticholinergic potential, leading to potentially harmful effects on the elderly. It has been found that older adults using medications that have anticholinergic features for just two months are at an increased risk for mild cognitive impairment.
However, it appears that not only is the length of anticholinergic medication use important, but also the strength of the anticholinergic agent. Malaz Boustani, MD, associate director, Indiana University Center for Aging Research, studying the issue of anticholinergic agents found that the risk for cognitive impairment increased by 50 percent in adults receiving at least 3 mild anticholinergic agents for more than 90 days and by 100 percent for those receiving one or more stronger anticholinergic agents for 60 or more days.
Common over-the-counter agents such as Benadryl, Sominex, Advil PM, Dramamine and many cold and cough suppressant agents that have dextromethrophan have anticholinergic properties. Many of these agents are taken quite regularly by many older adults for colds, sleep, and allergies, often unbeknownst to their physicians. However, physicians as well have been guilty of over-prescribing anticholinergic medications to older adults. Dr. Boustani states that physicians "absolutely" have been guilty of over-prescribing these forms of medications and often write these prescriptions out with ease and haste instead of sitting down and discussing possible alternatives with their patients.
Many commonly prescribed medications that are frequently used among many older adults have considerable anticholinergic effects. For instance, many drugs used for urinary or bladder issues, such as Oxybutynin, have considerable levels of anticholinergic potential. Furthermore, many medications for treating various forms of mental illness such as antipsychotic and antidepressant medications can have varying levels of anticholinergic potential. Even many agents used to treat Parkinson's disease, heart dysrhythmia, and vomiting just to name a few have anticholinergic properties that can adversely affect the cognitive level of many older adults.
It should be mentioned that the use of anticholinergic medications, although having the potential to lead to mild cognitive impairment, does not subsequently lead the older adult to the more debilitating state of dementia. As Dr. Boustani states, "We found that these medications are a risk factor for the development of MCI, but they are not risk factors for developing dementia." Furthermore, mild cognitive impairment caused by anticholinergic agents is a reversible condition.
Other studies have also found considerable issues with anticholinergic medications and the elderly. In fact, it was found that 23 percent of the medications used within a Medicare managed care population were potentially inappropriate. In fact, antidepressant and anti-anxiety medications were the most commonly cited medications, and it was found that the anticholinergic potential that many of these medications have is often overlooked by many physicians prescribing these medications for the elderly.
The pervasive anticholinergic impact found among many medications, the potential they can have for cognitive impairment, and the heightened sensitivity that many older adults have for these types of medications makes it very important for physicians to be especially mindful of prescribing these medications if alternative or optional modalities are available. Furthermore, older adults need to be more careful in the types of medications they use on an over-the-counter basis. In addition, using the expertise of the pharmacist and requesting their advice on medications that older adults may purchase which may have an adverse anticholinergic impact, many also help to forestall future cognitive impairment related to cursory medication usage. Physicians and older adults have to work together to ward off potentially negative effects of many medications that may ultimately have an ill-effect upon the cognitive health of many of our nation's older adults.
Anderson P. Just Two Months Exposure to Anticholinergics Affects Cognition. Medscape News, May 22, 2013: http://www.medscape.com/viewarticle/804558?src=wnl_edit_medn_wir&spon=34
Robinson DS. Anticholinergic Effects of Drugs and Cognition in the Elderly. Primary Psychiatry 2009;16(5):19-21.
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As the population ages, long-term care resources will be more in need. Older adults will comprise an increasingly larger portion of our total population, moving from 13 percent of our current population to approximately 20 percent over the next few decades. With this burgeoning growth in the population will come an increasing need for various forms of long-term care. However, a recent report paints a very costly and bleak picture for the affordability of long-term care services.
The report found that the national median private room rate for nursing care facilities in 2013 is $230 dollars/day, which is a 3.6 percent increase from 2012. The median annual nursing home cost increased $16,425 between 2008 and 2013. Moreover, since 2012, assisted living costs increased by 4.55 percent. In addition, costs for private home care providers continues to increase, often at a rate greater than yearly retirement income adjustments.
The report also states that in addition to this worrisome escalation in costs, many elderly have taken severe hits from the current recessionary environment, with many seeing their retirement savings depleted. Furthermore, many have also suffered severe reductions in the valuations of their property that they hold.
When you take these elements and add to it an increasingly growing elderly population that will be in need of various long-term care options without possibly being able to afford them, one can see that our country is possibly approaching a crisis situation for many older adults. Also, long-term care insurance is an option, but it is also a costly option and one that has not escaped the rising inflationary health care environment.
The report casts an ominous cloud for the future of many older adults. With health care costs increasing, an older adult population increasing, personal resources being depleted, and national resources already financially stressed, many older adults will be facing some significant anxiety-provoking challenges in the years ahead, especially for those that will need more extensive care due to some chronic and debilitating illnesses.
Kelly C. Covering the Rising Cost of Long-Term Care. The New York Times, May 14, 2013. www.nytimes.com/2013/05/15/business/retirementspecial/covering-the-rising-cost-of-long-term-care.html?ref=eldercare&_r=0
A novel exercise program known as Preventing Loss of Independence through Exercise (PLIÉ), has been demonstrated to hold possibly important benefits for those that suffer from dementia. Most forms of dementia, including dementia of the Alzheimer's type, are usually treated with medications to help slow the progression of the disease. However, many older adults suffering from dementia fail to demonstrate consistent and predictable results from the medications and some often fail to tolerate the medications.
Traditional exercise programs have often been targeted toward improving a person's physical health and functional level of existence. Those with dementia often can benefit from the physical improvements that exercise offer, especially in helping to improve their physical health that is frequently in decline. However, PLIÉ combines physical exercise that emphasizes functional movements with mindful body awareness to not only enhance a person's physical health, but also direct efforts toward maintaining a person's cognitive level of functioning as well.
Dr. Deborah Barnes from the University of California, San Francisco explained the results of her work with PLIÉ, and the results she has obtained from her research to those attending the 65th annual meeting of the American Academy of Neurology. Barnes states that the program "combines the best elements of eastern and western exercise traditions including yoga, tai chi, Feldenkrais, physical therapy, occupational therapy, mindfulness, and dance movement therapy." (1)
PLIÉ was especially focused on the maintaining and enhancing procedural memory, which is the more implicit memory that we use that helps to automatically and often habitually guide our daily movements and actions. Furthermore, conscious concentration or what Barnes referred to as techniques to increase awareness by focusing on "being in the moment" were used to help enhance one's cognitive abilities while engaging in the functional levels of exercise. Moreover, the exercise programs with those that suffered from dementia were often conducted within a circle. This helped to enhance the socially interactive features of the exercise group, allowing many of the individuals to communicate and interact freely with each other.
The results of the individuals that participated in PLIÉ were compared with those who had dementia but were given the traditional or usual care (UC). The study was small so the results have to be looked at cautiously. There were only six participants in the PLIÉ group and five in the UC group. The study ran for a period of 18 weeks. Pre- and post-intervention data were collected using the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-Cog), the Quality of Life in Alzheimer's Disease (QoL-AD), and the Short Physical Performance Battery (SPPB). Furthermore, caregivers were examined as well and their outcomes were measured as well.
The participants in the study, both those that had dementia and those who were caregivers, where closely matched on baseline characteristics and overall were quite similar on these characteristics. Briefly speaking, what stood out in the study was a noted improvement in ADAS-Cog scores (-4.6) in the intervention group, while the UC group experienced a worsening in their condition (2.4), for an effect size of 0.76. Dr. Barnes states that "This is substantially higher than what is usually seen with dementia medications, which is usually on the order of around 0.2 standard deviations." (1) Furthermore, the results were also positive for the caregivers as well. The investigators reported improvements in caregiver burden and caregiver distress scores as well.
As has been mentioned, one has to look at the results cautiously at this point due to the small number of participants that were studied. Nevertheless, one has to be optimistic, albeit cautiously optimistic, over the results that were obtained and further study in this area is definitely needed. Given that the treatment is much more holistic, being targeted toward not just enhancing the patient's physical health, but also enhancing their cognitive performance as well, it definitely needs to be looked at favorably for the greater depth and breadth of treatment intervention it can offer those with this debilitating condition.
Furthermore, since pharmacological interventions can often lead to serious side-effects, be quite expensive, and often provide very specific and limited treatment without the greater salubrious effects that this program has to offer, this in itself should be an impetus for much more research to be undertaken in this area. Since pharmacological therapy has not been the panacea that many have hoped for in addressing the problem of dementia, at least up to this point in time, providing an alternative form of treatment that is less passive and more dynamic, targeting the total organism in its treatment modality, and offering a more pervasive level of health enhancement for the person suffering from dementia may be a very productive avenue to entertain until better and more curative forms of therapeutic intervention exist.
1. Cassels, C. Novel Exercise Program May Trump Meds for Dementia. Medscape News. http://www.medscape.com/viewarticle/781607?src=wnl_edit_specol&uac=87637DR
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At this year's American Academy of Neurology's annual meeting, the discussion was focused on examining important biomarkers and their significance for diagnosing dementia. Dementia is a general term that often relates to a number of neurodegenerative disorders that often influence a person's memory and personality. Alzheimer's disease is the most common of the dementias. Traditionally, dementia has been diagnosed by ruling out other possible causes. In addition, typically the only way to fully provide diagnostic assurance of dementia is through autopsy.
However, recently new tests and biomarkers have been discovered that can provide greater assurance of diagnostic accuracy. These tests and biomarkers are not without a cost, however, both financially and psychologically. Therefore, even though science has progressed to provide use with a greater level of illumination into a clearer and more valid diagnosis, the question can be raised whether 1. they provide any greater efficacy for medical intervention since no cures exist for these illnesses; 2. the potential for false positives to exist can lead to psychological harm to the person receiving incorrect information; and 3. the potential for augmenting already exorbitant health costs, while not giving commensurate benefits to the patient. This is classic example of practicing medicine with no clear goals in which the means becomes the end in itself.
At the conference, three important biomarkers raised considerable interest. Hippocampal atrophy, decreased cerebral spinal fluid amyloid, and decreased brain glucose metabolism appeared to have a positive and cumulative association for dementia. In other words, those that had these biomarkers were more likely to progress to dementia, with those having all three being the most likely to eventually have a diagnosis of dementia. In fact, in one of the studies cited, only four percent of the individuals that failed to have any of the biomarkers progressed to dementia. However, 100 percent of those in the study that had all three biomarkers eventually acquired dementia.
An important consideration raised by many members at the convention was that there needs to be a standardized way to measure the biomarkers. This would enhance the validity of the tests as well. In fact, how biomarkers are measured may be more important than the type or amount of biomarkers used. Since there is so much variability currently in how many of these biomarkers are measured, this in itself can introduce considerable levels of error and reduce the accuracy of the testing.
It was found that an important biomarker, a positive amyloid beta marker, had a significant predictive validity for determining the progression of future cases of dementia. Among those that had a positive amyloid beta marker, 82% progressed to Alzheimer's disease compared with only 0 to 7% of those that were amyloid beta negative. However, 20 to 40% of the elderly who do not have any diagnosis of dementia also have amyloid plaques and are therefore positive for a amyloid marker and yet do not have any visible signs or symptoms of dementia.
Therefore, one has to weigh the costs and benefits of using such tests for diagnostic purposes. Consider if the tests provide any enhanced ability to provide therapeutic intervention and subsequently enhance the functional significance of a person's life. The argument for using these tests is that one is able to find out who will progress to dementia and therefore start aggressive treatment earlier, possibly before noticeable signs and symptoms appear.
The first concern is given the current levels of treatment for dementia, especially those of the Alzheimer's type, none of which has any cure associated with them, will starting treatment earlier really forestall the progression of the disease to any appreciable level? The second concern is if patients harbor biomarkers that may eventually lead to a particular dementia, this could have a significant psychological toll on the individual. A third issue is that some individuals have these markers but possibly may not have any signs or symptoms of the disease. Fourth, without any cures, does providing greater assurance of a proper dementia diagnosis really hold any significant medical value, especially for the patient?
Often in science, we may lose sight of the true goals, which in this case would be to benefit the person who has one of these dreaded diseases. Yet, if enhanced accuracy in this area fails to promote any potentially greater benefit such as attenuation of the symptoms or eradication of the disease, then the question arises, "Are we just enamored with the technology for measuring a particular biomarker?"
If this is the case, we have lost sight of the ultimate goal, which is to reduce or eliminate the disease. Finally, given the cost of such tests, which can cost thousands of dollars, multiplied by the number of individuals that may potentially get tested, this can augment our annual health care expenses considerably.
Therefore, the question that needs to be answered is whether the benefits of such biomarker tests outweigh the costs that may be incurred. It is difficult to jusitfy the costs given the very few, if any, benefits that may result with our current level of therapeutic knowledge for disease amelioration. This does not mean that the tests don't have any value in more specific cases. Nor does it mean that we as a scientific and medical community should shelve these tests. Currently, the ability to use a curative or significantly ameliorative intervention has not kept pace with our ability to find important biological makers. We have found some very important biomarkers that appear to be strongly associated with dementia may actually be used to enhance our progress toward finding better forms of therapeutic intervention to address these deadly diseases.
The establishment of firmly grounded biomarkers, although not at this time being an important therapeutic breakthrough for the amelioration of disease, may ultimately help to hone our ability in finding important curative interventions.
Stetka, B. S. (2013/April). Alzheimer Biomarkers in Clinical Practice. Medscape News. http://www.medscape.com/viewarticle/781533?src=wnl_edit_specol&uac=87637DR
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