Condition does not lead to dementia in most people

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. More than one in every eight people aged 60 and older is living with mild cognitive impairment, according to a special report from the Alzheimer's Association. And about a third of them will develop dementia within five years. Those are some sobering numbers, so for help understanding our individual risk, I'm talking with Dr. Sharon Brangman. She's the chief of geriatrics at Upstate, where she's a distinguished service professor and the director of the Center for Excellence for Alzheimer's Disease. Welcome back to "The informed Patient," Dr. Brangman.

[00:00:45] Sharon Brangman, MD: Thanks for inviting me.

[00:00:47] Host Amber Smith: The Alzheimer's Association report said from 12 to 18% of people aged 60 and older are living with mild cognitive impairment. Have they all been diagnosed or are there significant number of people with MCI who don't know it?

[00:01:02] Sharon Brangman, MD: Well, I think there are significant numbers of people who do not know it, and one of the main questions we get asked is, "I'm losing my memory. I think I have dementia because I can't find my cell phone or I can't remember the name of somebody who I've known for years. It's at the tip of my tongue." And those are some of the symptoms that we see with normal aging.

So as we age, our brain does undergo some changes that make it harder for some people to retrieve information. And I kind of explain it like a big hard drive full of information on a computer, and it has to start going through a lot of files to pull out the information. So you may see someone that you know, and you recognize their face and you can remember so many other things about them, but you can't remember their name. And it may take you several minutes or hours later to remember their name, but generally you can pull it up. Or you may be talking and you kind of lose your train of thought, but then after a period of time, you remember and you can get back on track. These are things that happen normally as we get older.

So if we think of our brain aging, like on a path where we're functioning normally, and then we might start to have problems with slow retrieval, and it may take us longer to remember someone's name, but we're still functioning normally. We can get through the day. We can take care of our finances. We can drive. We can dress ourselves. We can cook and figure out what to eat. You're still functioning normally. That is not considered dementia.

Mild cognitive impairment is a different entity along this path. And in mild cognitive impairment, people just feel like their brain is not working like it used to, and they feel like they have more memory problems than they should be having. But when we talk to them, they're still functioning normally. So it can get a little tricky sometimes to make that designation between what is normal aging and what might be mild cognitive impairment.

[00:03:32] Host Amber Smith: Does mild cognitive impairment affect men and women equally?

[00:03:36] Sharon Brangman, MD: Yes. It doesn't seem to have any gender specificity. Although women tend to get Alzheimer's disease more often, it doesn't appear that mild cognitive impairment has any specific racial or gender designations in terms of risk. And the majority of people with mild cognitive impairment never advance into dementia. About 80 to 85% may just have this aggravation where they just feel like they're not quite up to speed in terms of their brain power, but it doesn't get any worse, and sometimes it gets better over time.

[00:04:21] Host Amber Smith: So there may be people with mild cognitive impairment who never go on to develop dementia, is that what you're saying?

[00:04:27] Sharon Brangman, MD: Yes, that's absolutely true. But we focus on those 10 to 15% who every year do seem to progress into what we can then diagnose as Alzheimer's disease. And the trick about mild cognitive impairment is there's no definite x-rays or blood work or anything else that helps us make that decision. It really is left up to the clinical judgment of a physician who has heard these stories so many times and can start to sort them out.

There is a blood test and a brain scan that's a special kind of brain scan. It's called an amyloid PET (positron emission tomography) scan. And it can pick up abnormal buildup of this amyloid protein in the brain. And research has shown that if you have mild cognitive impairment and you have buildup of this abnormal amyloid protein in the brain, then your risk for progressing to full-blown Alzheimer's disease is very high.

[00:05:36] Host Amber Smith: So you could use that to try to help predict. Are there other clinical signs? Can you differentiate a person who has MCI who's going to go on and develop dementia versus the one who's not?

[00:05:49] Sharon Brangman, MD: No. There's no way by the story that they tell us, or a physical exam that we know the difference. And the challenge is, is that many insurance in companies, including Medicare, won't authorize coverage for an amyloid PET scan. So there's only rare cases where we can actually get that PET scan to see if they might have amyloid buildup.

There is a blood test that is being developed where we can do a blood sample and pick up those amyloid proteins in the blood, but it's still not completely approved by the Food and Drug Administration, and it's not readily available. So there may be an opportunity in the future to do a blood test, which would be cheaper than a PET scan, which is a specialized MRI of the brain. But right now it's very hard to get insurances to cover those.

[00:06:49] Host Amber Smith: Well, how do you go about diagnosing mild cognitive impairment, then, if someone comes in who's worried about forgetfulness or things that could be normal aging, but also could be mild cognitive impairment?

[00:07:02] Sharon Brangman, MD: So we have to listen to their story and listen to things that they're forgetting. And if it seems to be an accumulation of not just memory loss, but maybe problems making decisions or making decisions, especially where you need good judgment and problem solving, that starts to sound a little bit different than somebody who says, "I just couldn't remember somebody I saw this party, and I couldn't remember their name until I was driving home." There's nuances. There are nuances to it, and you have to go to someone who's experienced to help you sort it out.

[00:07:43] Host Amber Smith: Let's talk about treatment. What do you do for someone who you feel has mild cognitive impairment? Is there medication?

[00:07:51] Sharon Brangman, MD: So right now we are on the verge of getting approval from the Food and Drug Administration on new medications, if you do have that amyloid buildup in the brain, that may help to give you a few more months of stability if you have mild cognitive impairment. So as I mentioned earlier, if you have mild cognitive impairment and a PET scan shows that you have amyloid buildup, you have a very high risk for progressing to Alzheimer's disease.

And so these new medications remove this amyloid. They're very effective in removing the amyloid. And a couple of them that are under review for approval now show that they may reduce your progression for several months.

[00:08:43] Host Amber Smith: Are there any other diets or lifestyle changes, like common day-to-day advice? What are you able to tell people to try to do?

[00:08:52] Sharon Brangman, MD: We have a lot of non-pharmacological approaches, but as a society, we always want a pill. So we don't want to hear things unless there's a pill. But there's a lot you could do for brain health, and as I mentioned, some people with MCI, it gets better.

There are a number of things that we encourage people to do. The No. 1 is exercise. Exercise is probably better than any prescription I could write. And we try to tell people that they need about 150 minutes a week of good activity. And that could be walking. You don't have to run a marathon. It could be swimming. I recommend that my patients figure out a way to take a walk for a half an hour a day. You could break it up into 15 minutes, twice a day. But it's very important that we figure out a way to incorporate exercise into our life, just like we brush our teeth every day.

The other thing you want to do is make sure you get a good night's sleep, because when we are sleeping well, that's when our brain cleans up all these little abnormal particles that build up during the day. And research shows that when we're in deep sleep, that's when our brain cleans up all of these little particles. So it's important to get a good night's sleep.

The other thing that people usually don't like to hear too much is that alcohol really isn't good for your brain. You know, there were a lot of studies -- many of them were supported by the alcohol industry -- that said red wine was good for your brain. And we're starting to understand that alcohol is actually a toxin to nerves, and there is really no safe level of alcohol for our bodies in general and for our brains. So I try to encourage patients to keep alcohol use to a minimum and to stay away from the very high alcohol content beverages if they have to have a drink. But maybe just save it for special occasions.

The other thing is to not smoke, to control your blood pressure, If you have diabetes, control diabetes, and to eat a heart healthy diet. Any diet that helps your heart stay healthy helps your brain stay healthy because it's the same blood vessels that we're working on. And what they call the Mediterranean diet, minus the wine, is probably one of the healthiest diets you can have.

And then the other piece that's important is being socially engaged. If you have connections with people around you, if you volunteer in your community, if you have friends that you meet with regularly, it's important that you maintain social connections. And we're just coming out of a period where everybody was very isolated, and that took its toll on a lot of people and their brain power.

And then the final thing that's important is to make sure that you can hear well and that you can see well. Because if you don't get good sensory input from your ears and your eyes, then your brain has less to work with. And studies show that that can be a risk factor for developing dementia. And a lot of people don't want to wear hearing aids or they deny that they have a hearing problem. It's very important to get your hearing checked and have your vision checked and to get them corrected if needed.

[00:12:25] Host Amber Smith: That's interesting. I hadn't heard that before, but it makes sense.

Now, let me ask you a follow-up about exercise. If someone has not been physically active all along, is it too late to see benefit from this after they're diagnosed with mild cognitive impairment?

[00:12:41] Sharon Brangman, MD: No. The interesting thing is that people in their 90s who increased their level of activity actually do very well. So it's really not too late.

And again, I'm not talking about going out and running a marathon. It is just making sure that you walk and move every day.

The other thing to avoid are long periods of sitting still. There's a lot of research that shows that if you sit still for long periods of time, that's not good for your health. So I also tell my patients it's good every hour or so to get up and do a few loops around your house. Just so that you're not sitting for hour after hour on end. And that's true for younger adults who are middle aged, because you should really be thinking of brain health when you're in your 30s and 40s, because it's the same brain that's going to have to serve you when you're in your 70s or 80s.

[00:13:40] Host Amber Smith: What about crossword puzzles and memory games, jigsaw puzzles, things like that? Are those important or thought to be important?

[00:13:47] Sharon Brangman, MD: Those are things that I encourage people to do if they enjoy it, but if it frustrates you and it's making you aggravated, I wouldn't do it. It doesn't necessarily improve brain power. Our brains are much more complex than putting together a jigsaw puzzle. But if you enjoy doing it, that's fine. I would say do it with a group of friends so that you include socialization with it.

It's important to read and to listen to music and to use both sides of your brain, if you're creative, to paint or learn a language or do something new. You want to make sure that you're having different experiences.

Now, back in the day when I went to medical school, we were told that brain power starts to decline in our 30s or 40s. But we now know that you can continue to learn into your 80s and 90s. So you can teach an old dog new tricks. It's just that you might learn a little bit differently, but it's still good to learn new things because every time you learn something new, you make new nerve connections in the brain. And that's something that we want to keep doing throughout our lives.

[00:15:04] Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with Dr. Sharon Brangman. She's the chief of geriatrics at Upstate and the director of the Center for Excellence for Alzheimer's Disease, and we're talking about mild cognitive impairment.

Well, I understand that the majority of people who are diagnosed with mild cognitive impairment will not develop dementia, but for those who do, how fast have you seen that happen, and what is the progression like?

[00:15:35] Sharon Brangman, MD: So it's a very individual thing because it often depends on other risk factors that the person may have, and that includes hypertension, diabetes, high cholesterol levels, educational background and other things like that. But if we say over 10 to 15% of people convert every year, and the whole span of Alzheimer's disease could last 10 to 15 years. So it could take a couple of years to start to see more earlier signs and more definitive signs of Alzheimer's disease. And then once we make the diagnosis for early, it could take another six or seven years for someone to become moderate.

And these are all general rules of thumb because everyone is different. We're all individuals, and we're all products of our life events and our health and other things, so I'm talking in very general terms.

I've seen some people have very quick declines. And just the other day I saw someone in my office who I've been following since 2004, and I would say at this point they're more advanced, but they're still very functional. And so it's very hard to predict what each individual is going to experience with this really dreaded disease.

[00:17:00] Host Amber Smith: Is there any way for loved ones to try to get ahead and plan for what is coming or what this person may need as the disease progresses?

[00:17:10] Sharon Brangman, MD: So that's what we do in our office, and we have a great team of social workers and we try to help and an anticipate needs. The worst time to make a decision is in the middle of a crisis, so we try to help patients and families as they move along with this disease, make appropriate plans. And we can tell them some of the kind of guidelines we've come up with when we know when it's time to do the next step. And that's why it's so important to make an early diagnosis because then the person can participate in these discussions and in these plans. So then we know that we're doing things the way they would want them to happen.

[00:17:51] Host Amber Smith: When does a person with mild cognitive impairment have to stop working or driving?

[00:17:57] Sharon Brangman, MD: We usually recommend a driving test, for example, to assess somebody who is experiencing mild cognitive impairment. But for the most part, these are people who are still very functional. And they should still be able to live independently and take care of themselves and drive. And many are still working. It really depends on what they're doing. So it is not until we get to early Alzheimer's disease that we start to look at predictive safety measures to make sure the person stays safe and others around them stay safe.

[00:18:36] Host Amber Smith: How long can the person continue to make decisions for themselves, or how do you go about determining when they can't make decisions for themselves?

[00:18:46] Sharon Brangman, MD: So, that's a very good question. And again, it's a very tricky one because everyone is different. We can generally say that most people with mild cognitive impairment and even mild Alzheimer's disease can make decisions for themselves. Many people, not all, but many people with moderate Alzheimer's disease can make decisions for themselves and can still participate in their care.

By the time someone has advanced Alzheimer's disease, that is less likely to be realistic. And that's why we want to make sure when they're in their early stages that they select a healthcare proxy or someone who can represent their wishes when they're no longer able to do it. And that healthcare proxy has to be someone you trust, and it has to be somebody who will make decisions for you, not their own personal decisions. And that can get a little tricky. So those are some of the discussions that we start early on, so that someone has time to think about it and consider it and select the right person.

[00:19:52] Host Amber Smith: And make their wishes known either in writing or to a person that they trust?

[00:19:57] Sharon Brangman, MD: Exactly. We want to make sure that we're doing things the way you would want them to be done.

[00:20:04] Host Amber Smith: Is psychological counseling part of this along the way?

[00:20:08] Sharon Brangman, MD: So, yes. There are many people with mild cognitive impairment and even early Alzheimer's disease who would benefit from talk therapy. As long as you still have the ability to have some insights and to remember and follow suggestions, that sort of thing, there are a number of therapists in the area that we refer our patients to on a regular basis -- and sometimes not only the patient, but their caregivers and their families because, generally, this is a very stressful time and everyone needs some help and support getting through.

[00:20:47] Host Amber Smith: Are there medical issues that are more likely to arise in someone with mild cognitive impairment?

[00:20:55] Sharon Brangman, MD: A person with mild cognitive impairment would have the same medical issues that most other people have. And in our work in the Center of Excellence for Alzheimer's Disease, we find that there are many people with memory problems who have the triad, as we call it -- hypertension, diabetes, and elevated cholesterol or triglycerides -- because those are things that impact the health of our blood vessels. And the health of our blood vessels are very, very important for keeping our brains healthy.

The other thing we have found is that the brain is very sensitive to sugar levels. And, if you have diabetes, that means your body is having trouble managing sugars. And there are some studies right now looking at certain diabetes medications as possible treatments for Alzheimer's disease because some people with Alzheimer's disease have resistance to metabolizing or using their blood sugar. So just like you could have diabetes, you can have the same problem in the brain where the brain can't use sugars correctly. And that may increase your risk for dementia. So the brain is connected to the rest of our body. And if the rest of your body isn't healthy, your brain may not be either.

[00:22:25] Host Amber Smith: Well, the whole idea of dementia or Alzheimer's or mild cognitive impairment can be pretty scary to people, especially if they're grasping at remembering names and that sort of thing.

There's a lot of products available that promise to make your thinking sharper. I'm thinking of things like Prevagen and some of these other supplements. Is there anything that helps?

[00:22:49] Sharon Brangman, MD: I would say save your money, and don't use Prevagen. It does not work it. They have some very compelling commercials, but it does not work.

One interesting study that recently came out was that adults that took one senior vitamin a day seem to have better cognitive function over time. So we used to tell people that you can get all the nutrients you need from your food and you don't need to take any vitamins or vitamin supplements. But there is increasing evidence that, especially B vitamins, may be a little bit more trickier for our brains to work with as we get older. And so you might need a higher dose, or you might need more than you would've when you were younger.

In fact, we are going to be starting a clinical trial soon that's going to look specifically at that thiamine mechanism.

But in the meantime, I think it's a good idea to take a senior vitamin. And the reason why I say a senior vitamin is because they don't have iron in it. You don't want to take a vitamin with iron in it, because as we get older, there's no way for your body to get rid of that iron. And the iron can build up, and the iron is toxic to nerve cells. So when you look at vitamins that say "specially formulated for adults 65 and older," that would be the kind of vitamin you would want to take because it doesn't have iron. And if you can afford it, because sometimes vitamins can be expensive, I think it's a pretty low risk thing to take one vitamin a day.

[00:24:40] Host Amber Smith: Well, like you said, we're all looking for that magic pill, and it's just not there.

[00:24:45] Sharon Brangman, MD: It's not there. No, it's going to take a little bit more effort. And you know what? It has to start when you're 30 or 40. It's not one of those things that you just wait until you're 80. Although you still get benefits if you start when you're 80, if you want to maximize it, you've got to move back a few decades because all of the things we do to our body accumulate over time, and your body remembers it.

It's kind of like those people who played sports and hurt their knees or their hips, and then later on they've got very bad arthritis pain. And they need some attention to their knees and their hips. Well, the same thing is true for our brain health. We want to wear seatbelts so that if we get in an accident, we don't hit our head on the dashboard. You want to wear a helmet when you're riding a bike. You want to be very careful if your kids are playing football or soccer or hockey or lacrosse because head injuries, even when you're younger, can have implications on your brain health as you get older.

And we've all heard those stories of football players who were playing since peewee leagues, and in high school, and had lots of concussions. And then years later in their 30s or 40s, their brains are pretty beat up, and they start to get a form of dementia. So we have to take care of our bodies across the lifespan.

[00:26:16] Host Amber Smith: Well, this has been very informative, and I appreciate you making time for this interview, Dr. Brangman.

[00:26:22] Sharon Brangman, MD: Thank you for inviting me.

[00:26:24] Host Amber Smith: My guest has been Upstate chief of geriatrics, Dr. Sharon Brangman. She's a distinguished service professor and director of the Center for Excellence for Alzheimer's Disease at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.