Just this week (late August, 2016), I received my latest copy of the American Family Physician: it’s a handy journal for renewing my CME requirements and it’s a great reminder of basic family medicine protocols on a wide range of topics. One issue might cover insights about strep throat, fractured backs and cardiac rehab after a heart attack. Cover story this mid-August is on treating the behavioral disorders associated with dementia, typically referring to nursing home patients. The process is a medical treadmill and it goes downhill: because of symptoms of agitation, delusion, and fear, patients with dementia are started on a slurry of medications that are intended to calm but more often stupefy to the point where both the patient and her symptoms are no longer recognizable. It’s a sad process with not a lot of good options, once the disease has progressed to a certain point. Much as I appreciate the information, I better appreciate the reminder: if my practice were ever limited to handing out prescriptions, I'd rather wait tables.
In early August I had the incredible good fortune to attend the first practitioner training seminar hosted by Dr. Dale Bredesen and MPI Cognition in California, presenting his protocol which has reversed Alzheimer's related dementia as reported here. We first reviewed the pathophysiology—the details of what goes wrong in the brain of Alzheimer’s patients. My memory holds a very simplified version of the science: healthy brain connections don’t just sit there, they are actively maintained and nourished by every aspect of our system that has ever been shown to be associated with brain health. Communication from our blood stream (rich with hormones, vitamins, and also toxins, infections, etc.) to the master computer—the work going on inside the brain cells—occurs through protein bridges that span the distance between inside- and outside-cell areas. When anything goes awry and that protein senses a lack of the full nutrients needed, the connection is terminated and as part of the termination, the characteristic amyloid plaques of Alzheimer’s disease are formed from the fragments of the broken protein. The protein actually forms in response to three different potential situations:
- Inflammation in the area, whether from infection or just inflammation
- Loss of the hormones and vitamins that normally keep the protein bridges healthy, and
- Exposure to toxins
The amyloid plaques are formed by the body to protect the fragile proteins, to keep the problem localized, and to “downsize” the active portions of the brain, until the imminent danger (1,2, or 3 above) is resolved.
Most, but not all, of those who have early onset of memory-type symptoms have one or two copies of the ApoE4 gene. Most of us have two copies of ApoE3, and that puts us at moderate (one in nine) risk of getting Alzheimer’s, but having one or two copies of ApoE4 instead increases our risk by a factor of three or eight. ApoE4 instructs intracellular gene transcription and the resulting work done, and is influenced by all those hormones, vitamins, etc., swimming in the bloodstream.
Amyloid plaques are really only seen at autopsy, but we can infer their presence on a special functional scan of the brain. When we see its active volume reduced, we can infer that the plaques have sealed off once active areas. The plaques appear to be reversible, again by inference from the scans, this time showing restored brain volume in the dementia patients who have completed Bredesen’s protocol for one or more years.
The protocol is challenging; just the evaluation is challenging! The evaluation casts a wide net, in the hopes of identifying which of the five or six patterns best describes which of the normal brain-protective factors the patient with dementia has lost. Once identified, the patient’s responsibilities are complex, including dietary and lifestyle changes, supplements and possibly hormones to introduce, and it takes a while to see significant changes.
By three months, with good attention to the protocol, some improvement is apparent, and by six to twelve months, people report near-complete return of function. That progress is maintained for years, but only so long as the program is continued.
So here are my lingering questions from the vast input of fantastic information on brain health:
- Genetic testing: people are divided between embracing and shying away from it. I encourage people to be tested: the “program” is a lot simpler if you identify a genetic risk early in life and create new habits with a minimum of supplements, rather than waiting til later when there are more problems to deal with. I wonder what goes in to people’s decision-making, whether or not to test. I guess if someone thinks they are terrible at sticking with any program, perhaps they’d rather not know, so they don’t feel bad about being non-compliant with something new? I’m not sure about this one.
- The program is difficult: particularly for people who already have some degree of cognitive impairment, it’s hard to remember to re-load the supplement container, to empty its contents one or two times a day. Perhaps it’s hard to remember why one should avoid gluten, or what extra price you might pay for a mid-morning doughnut. I think the proper support will vary tremendously among individuals, and will require more attention to education (“Why Am I Doing This?” the name of a colorful brochure??) and encouragement (“This is hard, but the reward is so big!”) than most lifestyle shifts. I think health coaches will be part of the solution, but I know I will have to come up with some very clever solutions if I am going to be effective with more than one patient at a time!
The conference attendees will have access to a newly designed software program, so each patient's data can be entered and the likely-to-be-helpful interventions identified that are specific to that patient. I am already starting the work in a pre-software mode with some of my patients, and am looking forward to being able to offer the program to many more! I just need to figure out #2 above....
Any ideas, insights, or suggestions gratefully accepted at info@DrDeborahMD.com. Thanks.