Boosting the Brain

Michigan’s large senior population underscores need to help older residents maintain good cognitive health

Juanita* started noticing problems with her memory about three years ago, when she began regularly misplacing items and having trouble playing bridge with her club.

A neurologist referred the 66-year-old Troy resident to Henry Ford Health System for cognitive testing. She was diagnosed with mild cognitive impairment of the Alzheimer’s type, and she can expect to develop the disease.

“I was shocked,” Juanita says. “I wasn’t ready for it. But I was willing to take that PET [positron emission tomography] test even knowing it might be Alzheimer’s. That was a hard decision, too. A lot of people just don’t want to know. But I thought, I want to know what’s going on because that’s the only way, if I’m carrying the receptors for this, I need to prepare and learn about it and do everything I can to minimize the damage.”

Juanita is not alone. Michigan has the eighth-highest population in the United States of people age 65 and older, according to the 2010 U.S. Census. About 14 percent of Michiganders are older than 65, a proportion that is likely to only grow as more baby boomers enter their golden years.

The fact that Michigan is home to large swaths of the senior set raises a host of public health and policy issues, among them the need to help older residents maintain good cognitive health. In 2010, Alzheimer’s was the fifth-leading cause of death among the older population, according to the report “65+ in the United States: 2010” by the U.S. Department of Commerce. The death rate from the disease rose more than 50 percent between 1999 and 2007.

And Alzheimer’s is just one cause of dementia. Certain nutritional deficiencies, stroke, and diabetes are also linked to cognitive decline, as are other disorders such as Parkinson’s.

The good news is that many of the causes of dementia are preventable, and even Alzheimer’s can often be slowed through changes to diet and activity.

“Early cognitive impairment is an excellent time to intervene with lifestyle changes that can change the course of the disease over time.”

– Kate Pierce

Juanita says she and her husband have had to adjust some aspects of their daily lives. She’s gotten serious about exercise, aiming for a 45-minute walk every day, and the couple began wintering in Arizona so they could be more active. During a trip to Mexico, she forced herself to swim an underground river, in a bid to try new things and stretch herself cognitively. She also stopped drinking alcohol and enrolled in a watercolor class.

Those are all good choices, says Kate Pierce, a care counselor/social worker with the Alzheimer’s Association, which works with Henry Ford Health System in its memory clinics. “Early cognitive impairment is an excellent time to intervene with lifestyle changes that can change the course of the disease over time,” she says.

In fact, Alzheimer’s disease may begin as much as 18 years before symptoms appear, according to a study published in June in the journal Neurology. Taking steps to protect one’s cognitive health should begin as early as possible.

Preserving cognitive health

Up to 20 percent of Americans 65 and older have mild cognitive impairment, according to Dr. Deborah Levine, assistant professor of medicine at the University of Michigan. Mild cognitive impairment falls between normal function and dementia, and is defined as impairment not severe enough that the person needs help with daily living.

“Cognitive decline is a common and feared aspect of aging,” Levine says. At the request of the Journal of the American Medical Association, Levine and her colleague, Dr. Kenneth Langa, conducted an exhaustive review of the literature and studies related to the diagnosis, treatment, and prognosis of mild cognitive impairment in older adults.

That review helped yield four key recommendations for protecting cognitive health:

Optimize your cognitive reserve. The higher a person’s education level, the less susceptible he or she is to cognitive decline. Consider enrolling in a class or taking an education course on DVD; the key is to learn something new and stretch the brain.

Control vascular risk factors and engage in physical activity. Regular aerobic, strength, or balance exercises can have a significant positive effect on brain health. Aim to schedule 150 minutes of aerobic exercise per week; brisk walking counts.

Avoid brain injury. According to Levine’s research, a stroke takes eight cognitive years off a person’s life. “Stroke is a potent risk factor for cognitive decline and dementia,” she says. “It can trigger the manifestation of Alzheimer’s and worsen cognitive decline.” Fortunately, about 80 percent of strokes are preventable. A healthy diet and exercise can help control risk factors like high blood pressure, diabetes, and high cholesterol.

Ensure adequate blood and sugar flow to the brain. Low blood pressure and blood sugar are associated with the future development of dementia. “With diabetes, in the effort to control blood sugar, it’s common that patients at times will have episodes of low blood sugar to get to that tight control, which can be dangerous,” Levine says.

Check for hidden culprits

Cognitive impairment rarely results from a single root cause, experts say. Rather, problems pile up — high blood pressure, say, combined with poor sleep — to cause decline.

“Usually the brain is capable of sustaining one blow; a patient can have Alzheimer’s and still do very well,” says Dr. Marina Novikova, attending physician at Henry Ford Health System and head of its memory clinic. “But if you add on other factors — like sleep apnea, medications, diabetes — the combination causes you to have cognitive problems. The idea is to uncover all players and remove as many as we can.”

If you or a loved one seems cognitively impaired, consider taking a sleep test. “Sleep apnea is not looked at frequently enough at as a reason [for cognitive problems],” Novikova says. “People think they just snore — that everybody snores. A lot of people are overweight and they snore and usually have sleep apnea.”

Another recommendation is to check hearing and vision. “If people aren’t the getting right information in the first time, they won’t be able to encode it and retrieve it,” Levine says. “Making sure your hearing is adequate and that your glasses are adequate makes a huge difference.”

“Usually the brain is capable of sustaining one blow; a patient can have Alzheimer’s and still do very well.”

– Dr. Marina Novikova

Finally, a review of medications may be in order. The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, known as the Beers List, provides guidance to physicians on medications to avoid prescribing to the elderly. Nonetheless, Levine says, many older adults are prescribed them, and they can negatively affect cognitive ability. Benadryl, Tylenol PM, sleeping aids, and medications for bladder problems all can affect cognition.

Brain food

Diet is a key factor is maintaining good cognitive health. Research indicates that nutrients in the foods boost the brain, and a healthy diet also helps to prevent stroke.

The MIND diet (Mediterranean-DASH Intervention for Neurodegenerative Delay), which combines the Mediterranean and DASH (Dietary Approaches to Stop Hypertension) diets, appears to go even further than either diet on its own in helping to prevent cognitive decline.

According to a recent study published in Alzheimer’s & Dementia: The Journal of The Alzheimer’s Association, which followed 923 older adults for several years, individuals who followed a MIND diet were up to 53 percent less likely to develop Alzheimer’s during the study’s time period.

The MIND diet entails cooking with olive oil and consuming:

• Three servings of whole grains daily

• Two servings of berries weekly

• Six servings of leafy greens weekly

• One vegetable serving daily, in addition to leafy greens

• One serving of fish weekly

• Two servings of poultry weekly

• Five servings of nuts weekly

• Three servings of legumes weekly

• One glass of alcohol daily, preferably red wine

Skip fried food and fast food, limit red meat intake to once a week and butter to less than a tablespoon a day, and eat sweets sparingly.

Having the talk

Another key part about cognitive health and avoiding problems is talking about it with family and friends.

Often a person’s cognitive impairment is noticed first by loved ones, and broaching the topic isn’t easy. “Usually about half of the people I see are acknowledging their memory changes and they’re worried about it, and that’s the initiative to come in and get evaluated, and about half are completely in denial, which causes a lot of tension with whoever is bringing them in,” Novikova says. “There are many things that are not observable to a person, for example, repeating oneself. Usually people who are doing that aren’t aware of it and are very frustrated when it’s pointed out.”

No one likes to be told they’re not as sharp as they once were. That’s why Novikova advises avoiding confrontation and trying instead to frame the conversation in neutral terms.

“So it’s [saying], ‘Let’s go for a regular checkup.’ Make it more neutral, not necessarily pointing out deficiencies and issues, and saying, ‘I’m concerned about your memory.’ ”

*Last name withheld. 

Support for caregivers

In April, U.S. Sen. Debbie Stabenow, D-Lansing, introduced legislation to increase access to information on care and support for people newly diagnosed with Alzheimer’s, as well as their families.

The HOPE for Alzheimer’s Act (Health, Outcomes, Planning, and Education) also would ensure that an Alzheimer’s or dementia diagnosis is documented in the individual’s medical record.

The act is consistent with recommendations made in the Department of Health and Human Services’ National Plan to Address Alzheimer’s Disease, released in 2012, including the need to enhance assistance for people with Alzheimer’s disease and their caregivers.

Terry Trost, a Waterford resident whose wife of nearly 40 years, Vickie, died in August at age 58 from early-onset Alzheimer’s, witnessed firsthand the challenges faced by patients and their families. When his wife died, he insisted that Alzheimer’s disease be put on her death certificate as a cause of death.

“Alzheimer’s has a stigma with it,” he says. “People have got to get away from that. I feel that Alzheimer’s is not recognized and we don’t get the funding for it partially because people don’t have it put on the death certificate.”

During his wife’s illness, Trost leaned heavily on the social workers at the Alzheimer’s Association Greater Michigan Chapter for advice.

His advice to his fellow caregivers is to take full advantage of the association’s programs and support groups, and to learn as much as possible about the disease. And, he says, accept the diagnosis so that you can enjoy the time you have.

“Honest to God, we had so much fun,” he says of his last months with his wife. “I’m not happy how it ended, but we had caregivers at the house, and I’d come home from work and she’d be rubbing her hands, waiting for me. I’d tell her she looked beautiful, and I would ask her if she wanted to go on a dinner date. Every night we went to dinner at the same place. She was my love. You just deal with what’s there.” —Alexa Stanard