Proven and practical ways to slow or prevent cognitive decline

When we get sick, all too many of us respond reflexively: Ring up the doctor, wolf down some prescribed pills, and everything, we hope and trust, will turn out fine.

That approach is problematic on many levels, especially because it often does not work. Big Pharma may be riding high these days, what with its development of miraculous coronavirus vaccines. But drug makers absolutely have not come up with treatments for all of humanity’s major ills.

This is especially true with dementia and the cognitive condition’s best-known form: Alzheimer’s disease. Sure, the news has been full of reports that the federal Food and Drug Administration just granted an accelerated approval to a prescription medication from Biogen aimed at Alzheimer’s — the first such drug to win such an endorsement in a decade.

But there are huge concerns about this medication, the medical theory underlying it, the research that won its regulatory nod, the process by which it was reviewed — not to mention the drug’s sizable cost, which is certain, and its safety and effectiveness, which are uncertain.

While advocates hope it opens frontiers in dementia treatment, this medication may have another powerful effect: reminding us all that we can do things besides taking drugs that can help delay or prevent debilitating conditions like Alzheimer’s.

Can we think ahead, be savvier, and protect our brains with healthful behaviors? No need to scratch your head as to what’s involved — the figure above provides a map to ideas that experts want all of us in a fast-graying nation to act on to reduce dementia’s burdens.

Few diseases terrify older people as much as Alzheimer’s does. With reason. It can strip seniors of their memory and cognitive capacity, leaving them incoherent and dazed. It can cause them to grow agitated and to wander aimlessly.

Patients with dementia may lose control of bodily functions and require 24/7 care — much of it, sadly, provided by exhausted spouses and other loved ones. Family members may not only be financially drained by caregiving but also could be subjected to physical struggles with demented loved ones, who may say inappropriate things and act in inexplicable ways.

The burdens of the disease — and the absence of treatments for it — can create despair. Just look at those worrisome national statistics on the illness’s increasing costs and rising incidence (see By the Numbers on right rail).

But is the condition daunting enough so that people will take evidence-based steps to delay or prevent it? Maybe so, experts say, especially because a growing body of research suggests how.

Alzheimer’s and dementia, for now, can be tough for doctors to detect early, diagnose its different forms and causes, and treat it (see sidebar below). There are many theories, specifically about Alzheimer’s origins (more about that in a bit). But many of the evidence-based preventive measures may be familiar, unsurprising, and based in common sense.

Good for the body, good for the brain

In brief, what’s good for the body also can be beneficial to one of its largest and most commanding organs, the brain.

Experts recommend that we protect our cognitive capacities with regular vigorous exercise, as well as a well-balanced, plant-heavy diet — eating that focuses on less fat, sugar, and salt, and that favors fish and nuts over beef and pork. Think of a meal plan built around the popular “Mediterranean” or “DASH” (blood-pressure reducing) diets.

To protect optimal brain health, skip the tobacco smoking and vaping, of course, and go easy on the intoxicants, whether alcohol or substances like marijuana. Older people need to be wary of anticholinergic drugs (including antihistamines and some antidepressants) as well as benzodiazepines (Valium, Xanax for anxiety and sleeplessness). These have been linked to delirium, cognitive impairment, and dementia. Some people need to take these drugs, but they must be aware of the side effects.

We need to manage our weight to protect our hearts and lungs, and work with our doctors to manage our blood pressure (hypertension) and ensure we don’t develop diabetes.

All this advice may sound most on point to those wishing to stay fit and spry. But this advice also addresses challenges that experts know can result in cognitive damage. Research, for example, underscores that vascular and circulatory problems may be the second most common cause of dementia. It often occurs, say, after patients suffer repeated strokes or prolonged and uncontrolled high blood pressure.

Avoiding head trauma

Dementia also can result from physical damage to the brain. Doctors long have identified cognitive declines linked to substance abuse, especially excess consumption of alcohol.

Those who suffer repeated blows to the head — especially in athletics and without protective gear — also can show cognitive impairment that can be a kind of dementia. The harms of concussions are so well-known they have entered the lexicon in phrases like “punch drunk.” Sadly, in our era of hero worship for pro players, we’re also seeing too many stars of yore in boxing, football, and other competitive athletics enter their golden years, if they get there, with mental impairments.

Still, parents and young athletes are showing greater awareness of the risks and long-term perils of concussions and repeated blows to the head. Coaches and organized sports programs are rushing to provide improved protective gear and to avert unnecessary contact to the head in an array of amateur athletics. A billion-dollar settlement the National Football League reached over players’ head and brain injuries also shows that pro leagues may be committing more to protecting their people.

Social engagement and intellectual stimulation

When it comes to safeguarding cognitive function, studies show that keeping the brain at work appears to be important to preventing its decline. It appears to be true that minds can get mushy if left alone and taxed insufficiently.

This can mean that we need to stay socially engaged and keep up robust engagement with friends and loved ones. Recent studies have shown that lack of purpose, loneliness, isolation, and depression take a terrible toll on the spirit, mind, and body. Health workers, caregivers, and family members have, for example, reported major declines in the well-being of residents of nursing homes and other long-term care facilities during lockdowns ordered during the coronavirus pandemic.

Besides social engagement, the brain must be stimulated and challenged to some degree to keep up its optimal state, studies show. A cottage industry has cropped up purporting to offer intellectual stimulation via puzzles, games, and online and video products promoted as “brain exercises” for older adults. The jury’s out on the outcomes generated by, for instance, knocking out a daily crossword puzzle or taking regular online quizzes or courses. Studies haven’t found the major benefits suggested by aggressive advertising and marketing campaigns.

Keep up the sleep, hearing, and vision

Research has pointed out the importance of some lesser-known ways that people can benefit their brains and slow or possibly prevent Alzheimer’s and other forms of dementia: We need to get plenty of sleep. And we need to do all we can to ensure we see and hear well.

Experts will be unraveling the mysteries of sleep for a long time. But well-accepted theories suggest that crucial functions occur in the brain during the time many of us think we just doze. The brain uses our sleep time to process and record our experiences, including cleaning up processes that may have gone awry during the waking hours. We also may transfer temporary perceptions to longer-term memory during sleep. At a biochemical level, the brain may use sleep time to clear out harmful substances, such as the proteins and tangles of them that an influential theory holds may be a cause of Alzheimer’s.

As for our sensory wellness, a growing body of information is telling experts that decreased hearing and vision can trigger significant cognitive declines. When older adults cannot see or hear well, their social and intellectual engagement can plummet, with bad consequences. Because women live longer than men, they may experience greater incidences of hearing and vision impairment and loss that becomes dementia-Alzheimer’s. In fact, over a lifetime, women have twice the risk that men do of developing Alzheimer’s.

Key concepts matter in understanding where we stand in dealing with dementia.

As of now, we lack the big C — a cure or effective treatment.  Don’t be gulled by hucksters who say otherwise, for example, claiming without evidence that dietary supplements work magic on the brain.

If you are confused by experts describing an aggressive search for delaying dementia rather than remedying it, there are good reasons why. The earlier the onset of the disease, the greater its burdens. As mentioned, it can be costly and difficult to care for those with the disease. Putting off the onset as near as possible to the natural end of patients’ lives could be helpful.

Important caveats also need to be made clear about recommended preventive steps, as the Alzheimer’s Association, a leading patient advocacy group, does in its online information:

“Insights about potentially modifiable risk factors apply to large population groups, not to individuals. Studies can show that factor X is associated with outcome Y but cannot guarantee that any specific person will have that outcome. As a result, you can ‘do everything right’ and still have a serious health problem or ‘do everything wrong’ and live to be 100.

“Much of our current evidence comes from large epidemiological studies such as the Honolulu-Asia Aging Study, the Nurses’ Health Study, the Adult Changes in Thought Study and the Kungsholmen Project. These studies explore pre-existing behaviors and use statistical methods to relate those behaviors to health outcomes. This type of study can show an ‘association’ between a factor and an outcome but cannot ‘prove’ cause and effect. This is why we describe evidence based on these studies with such language as suggests, may show, might protect, and is associated with.

“The gold standard for showing cause and effect is a clinical trial in which participants are randomly assigned to a prevention or risk management strategy or a control group. Researchers follow the two groups over time to see if their outcomes differ significantly. It is unlikely that some prevention or risk management strategies will ever be tested in randomized trials for ethical or practical reasons. One example is exercise. Definitively testing the impact of exercise on Alzheimer’s risk would require a huge trial enrolling thousands of people and following them for many years. The expense and logistics of such a trial would be prohibitive, and it would require some people to go without exercise …”

Lest anyone think that the “fine print” cautions about lifestyle and other preventive measures undercuts experts’ enthusiasm for their use in delaying or preventing Alzheimer’s-dementia, they would be mistaken. This has become clearer due to federal regulators’ recent dealings with a prescription drug promoted for Alzheimer’s treatment.

There’s a four-letter word for patients and families who have heard about a new drug for Alzheimer’s and are racing to get their doctors to prescribe it for them — whoa!

Critics have assailed the Biogen drug, brand name Aduhelm, arguing that it provides unfounded hope and too many negative lessons about the search for a safe and effective Alzheimer’s drug.

Aduhelm is Biogen’s answer to a leading medical theory as to the cause of Alzheimer’s: that the protein amyloid clumps into tangles and plaques in the brains of patients and fouls up their cognitive processes. Biogen says that Aduhelm, a monoclonal antibody, helps to clear amyloid from patients’ brains.

But this hypothesis, despite billions of dollars of spending, notably by Big Pharma researchers, has not been proven. Indeed, it is falling into disfavor and without a replacement. That’s because even if Aduhelm and other experimental drugs reduce amyloid in the brain, clinical studies have not shown that this improves or extends patients’ lives.

Federal regulators, though, can give an accelerated approval to prescription drugs based on research on what is known as “surrogate endpoints,” substitute criteria that might include, say, whether a cancer medication shrinks a tumor or seems to delay certain symptoms. That is not the same as more pertinent criteria, such as improving or extending patients’ lives, critics say.

They say Aduhelm is only the latest Big Pharma product that will be costly for patients, families, and taxpayers, with a bit of benefit, at best.

Diagnostic screens and sustained testing

Those racing to get the drug must know that doctors are not supposed to prescribe it casually — say, if older patients want to take it preventatively or if they experience occasional but worrisome memory lapses.

Doctors are supposed to require patients to undergo extensive, invasive, and expensive testing to diagnose them with Alzheimer’s and make them eligible for Aduhelm. This likely would include imaging studies of their heads to see if they show plaque buildups. The screens can cost several thousands of dollars.

And remember, doctors already struggle to differentiate dementia causes — whether by amyloids, vascular problems, brain damage (due to physical shocks or substance abuse), or issues with alpha-synuclein, a protein associated with a Lewy body disorder that also has been tied to Parkinson’s.

If patients get the go-ahead to take Aduhelm, they face further challenges. They must take it monthly as an infusion, typically given over an hour’s time in a doctor’s office, clinic, or hospital. They also must undergo regular and sustained monitoring, including those pricey head scans, because Biogen has warned that its medication can cause brain swelling and bleeding.

Those issues, of course, cropped up when Biogen ran not one but two clinical trials of its drug. After its trials, the drug maker announced it was abandoning the product into which it had sunk huge sums. But it then reexamined and reinterpreted data from its studies, arguing that its after-the-fact analyses showed its drug was useful and should be approved.

The FDA’s independent experts, however, tore apart Biogen’s research and advised the agency — in stark terms — to reject the drug. When their advice was disregarded, members of the elite panel resigned in protest.

Billions of dollars in prospective new costs

Biogen has added insult to injury, critics say, by deciding that it will charge $56,000 annually for Aduhelm. That is far above the $2,500-$8,000 annually that an independent panel of experts had recommended as fair.

Here is the flummoxing part of the drug and its approval: Biogen’s clinical trials focused on Aduhelm’s potential effects on early-stage Alzheimer’s patients. But federal regulators seemed oblivious to this important distinction. They instead have allowed the company to market the drug for at least nine years to all Alzheimer’s patients, with zero evidence of its effects on those with more advanced cases.

Further — and this is the part that affects all of us who pay taxes — the actions by the federal Food and Drug Administration typically now clear the way for Medicare and Medicaid to be required to pay for Aduhelm for seniors if doctors prescribe it. This puts the U.S. Treasury on the hook for billions of dollars in new spending on prescription drugs, just as consumers are howling about medicines’ already skyrocketing costs.

The United States, as things stand now, could spend more on Aduhelm alone than it does for the space agency NASA. (Remember, due to fierce Republican support for Big Pharma, Medicare officials are blocked from negotiating on prescription drug prices.)

The FDA has said that its approval was based partly on the overwhelming need for patients and families to find some ray of hope in Alzheimer’s care. That is a moving reason, but it is not part of the rigorous scientific and regulatory rationale for judging the safety, effectiveness, and cost of prescription drugs. The agency also has said Aduhelm will need further clinical trials because its approval was accelerated and conditional.

Big or small (measured) gains?

Biogen appears as if it will have roughly a decade, though, to sell Aduhelm and to rack up huge profits from it. If this Alzheimer’s drug can squeak by regulators, maybe others of its kind will, too, given the precedent the FDA has set. Will this be viewed in the long term as the agency opening the door to steady advances in dementia treatment with prescription medications, as some groups have suggested? They point to slow FDA oversight on HIV-AIDS treatments that may have delayed progress and cost the lives of far too many. Or will patients and physicians find themselves besieged by tough choices on Alzheimer’s drugs with huge costs and small benefit?

Here’s another key consideration about Aduhelm. As the Associated Press reported on a central measure of the drug’s effects:

“Patients taking [the drug] saw their thinking skills decline 22% more slowly than patients taking a placebo. But that meant a difference of just 0.39 on an 18-point score of cognitive and functional ability. And it’s unclear how such metrics translate into practical benefits, like greater independence or ability to recall important details.”

The urgency to find safe, effective, and affordable ways to deal with dementia and Alzheimer’s has only accelerated due to yet another costly complication: the rising need for and expense of nursing home and other long-term care for the aged, ailing, and injured.

The prospective demand for such services is huge. As researchers at the Pew Foundation reported, “on this day and for every day [for a decade or so more], 10,000 baby boomers will reach age 65.” While a decade ago, “just 13% of Americans [were] ages 65 and older … [b]y 2030, when all members of the Baby Boom generation have reached that age, fully 18% of the nation will be at least that age.”

Here is what researchers at the independent, nonpartisan RAND Corporation have reported about the stunning burdens individuals and the nation will confront with dementia care:

“A RAND study published in 2013 …. —the most-detailed examination done in recent decades on the costs of dementia — found that dementia already takes a higher economic toll than heart disease or cancer: at least $159 billion a year, and possibly as much as $215 billion. Nearly 15% of Americans older than 70 —some 3.8 million people — already have dementia, the RAND study found. That number will swell to 9.1 million people by 2040, it calculated, more than the current population of New York City. At that point, the cost to care for them could exceed half a trillion dollars a year, according to Michael D. Hurd, the study’s lead author, an economist by training, and director of RAND’s Center for the Study of Aging.

“Even if the rate of dementia slows, as some recent studies suggest it might, the overall number of people getting sick will continue to balloon as the population ages, and with it the costs.”

Problems laid bare by coronavirus pandemic

The coronavirus pandemic exposed the nation’s crisis in nursing homes and long-term care, with roughly a third of diagnosed deaths and tens of millions of infections occurring at institutions housing the vulnerable old.

That has led families to rethink existing facilities, which struggle with huge problems like infection control and inadequate staffing. Studies have shown that the coronavirus ripped through nursing homes, partly because their health workers were overworked, stressed to the max, under-trained, and underpaid.

Nursing homes already charge sky-high rates, with the nationwide average cost for a single bed running around $100,000 annually. “Memory care,” the intensive 24/7 services required by dementia patients, can be some of the priciest long-term care around. Because so many seniors have exhausted their own finances, the federal government has seen its costs head alarmingly northward to pay for seniors’ long-term care.

If you’re younger and haven’t done so, you should sit down with your financial advisor (or maybe the people who help your parents or other older relatives with their money) and assess your saving and other preparation for old age. You should put your mind to the ever-increasing cost of medical services as you age. And you may need to determine not only the status of your retirement accounts but also the utility of long-term-care insurance policies, which may be more affordable if you get one long before you need it.

You may want to be more rigorous about adopting some of the preventive steps outlined above. And you may want to pause and reconsider your views on age and infirmity.

An inflection point?

The whole country could hit a turning point, when we no longer try to make older people disappear, preferring to chase perpetual youth. We are making strides in appreciating how our differences should not divide us but should be seen as strengths and causes for celebration. We’ve got a long way to go in dealing with inequities rooted in race, nationality, gender, and sexual orientation (to name a few of the human characteristics our society is reckoning with).

Friends and loved ones of those with dementia and Alzheimer’s say they can be overwhelmed, not only by the demands of caring for sick loved ones, but also by the stigma that is attached to seniors’ natural decline as they age. We’ve learned to see the joy that young athletes can find in programs like the Special Olympics.

But we get embarrassed, turn away, and shun older adults who venture out in public with their caregivers and act “demented,” or lacking in personal control.

Caregivers can testify that those with cognitive conditions aren’t always unruly or inappropriate. They can have moments of clarity and happiness, as when some Alzheimer’s patients receive music therapies. We need to accord greater dignity to those with cognitive impairment in old age. We can reset our expectations. We must appreciate the incapacitated for who they are and what they can do, not wishing for them to magically be what they once were and what they used to do. We must enjoy our time with all our friends and loved ones and support their caregivers.

Here’s hoping that you’ve gotten helpful ideas about staying mentally and physically fit and well — throughout 2021 and beyond! May you have an old age with remarkable good health, laughter, and love.