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Mind Your Brain Now, Or Risk Losing It Later

There was quite a stir a few weeks ago when European researchers reported that measurable cognitive decline can be detected in people as young as 45 - a good 15 years earlier than has been generally thought. The study led by French researcher Archana Singh-Manoux examined data from Britain’s ongoing Whitehall II health study—8,000 people, aged 45 to 70, whose memory, mental reasoning and language has been tested and assessed three times since 1997. It found declines at all age levels, and in every test except vocabulary, which is the only aspect of mental ability that has been found to be unaffected by age. Though not surprising news to anyone who’s been following research of Alzheimer’s disease and brain aging, the study is something of a landmark because it’s the biggest and most compelling to date documenting how senior you have to be—not very—before the senior moments start. It’s strong evidence that our brains age gradually over decades, much like other organ systems, and it holds important implications about the onset of more serious deficits, ranging from the condition known as mild cognitive impairment all the way to full-bore Alzheimer’s. “The declines among people in their 40s and 50s were modest,” said Singh-Manoux, “but they were real.” It’s an attention-getter that could turn out to be a game-changer. I hope it does. There’s a real wake-up call in this study, and it’s that we should be paying as much attention to our brains as we do to our hearts and lungs, and not wait until we’re old enough for Social Security to do it. Contrary to common perception, there are ways to measure, monitor and improve your brain health. Maybe even lessen your risk for Alzheimer’s disease. In fact, some of the same lifestyle and nutritional strategies we use to prevent cardiovascular disease can also keep our brains fit and stave off the mental declines that come with age. The French-British study, published in the British Medical Journal, drew lots of media coverage and at least one instance of tongue-in-cheek hysteria. “Life Ends at 45,” was the headline, a turn on the old life-begins-at-40 bromide, and no, it wasn’t in The Onion but in Britain’s The Independent. Black humor, sure, but maybe not so funny to anyone who believes that the first hint of aging marks the beginning of the end. Well, life neither begins nor ends at 45, but it is an age when people typically start noticing the subtle signs of the aging processes that actually begin 15 or 20 years earlier. And it’s a good time to start paying attention. Unfortunately, when it comes to your brain, that message hasn’t made its way to traditional medicine. Physicians commonly use the term “subclinical” or “preclinical” when a lab result shows someone is well on a path to a particular disease but hasn’t hit some arbitrary magic number or experienced any symptoms. They diagnose subclinical coronary artery disease, for instance, and prescribe measures to prevent a heart attack or stroke. Even preclinical cancer is so well-defined that it has a name: carcinoma in situ. But early detection and treatment of age-related brain disease lags far behind. There is no generally recognized assessment for what might be called subclinical dementia as there is for the precursors of the other diseases of aging, and little consideration given to prevention. It’s not very hard to see why. The brain’s disease of aging is Alzheimer’s—the most devastating and vexing of them all. Alzheimer’s is an epidemic—50 percent of people in their 90s have it and it strikes 5 to 10 percent of those as young as their 60s—and the numbers will only grow as people live longer. These numbers are particularly grim for a disease that has no significantly effective treatment and traditional medicine hasn’t caught on to early detection and prevention as a viable strategy.

Reading upside-down and other cognitive calisthenics It’s not so much that the only lab test that can definitively diagnose Alzheimer’s is an autopsy. The symptoms are all too painfully obvious. The real problem is treatment. Coronary bypass grafting and angioplasty can take critically ill patients and add quality years to their lives. (Just ask Bill Clinton.) But there is nothing like that for Alzheimer’s. By the time it is diagnosed, there’s already been significant decline that can’t be reversed or stopped. Even the best available therapies can only slow the decline—and only modestly. This stark reality has colored the way researchers—and the public—think about early diagnosis, much to the detriment of both our individual and collective health (including financial: The cost is already said to exceed the annual revenues of Wal-Mart). Even my health-conscious patients reflect this mindset when they decline my recommendation to take a cognitive health test. “If there’s nothing I can do about it,” they tell me, “I don’t want to know about it.” But the fact that there are no treatments on the horizon for Alzheimer’s does not mean there’s no value in testing to see if you are at increased risk for it. Because there actually are things you can do about it---if you start early enough. Perhaps an analogy with the common cardiac stress test can help explain why. In 25 percent of people, the first manifestation of coronary artery disease is a heart attack. They don’t have the chest pain or shortness of breath that heralds a critically narrowed artery which can shut down and cause a heart attack. But a stress test can detect a potentially fatal hidden problem. It challenges the ability of your coronary arteries to deliver oxygen to your heart muscle by exercising you to the brink of your maximum heart rate. If your arteries are more than 75 percent narrowed (and at considerably increased risk for a cardiac event in the next five years) you will likely have chest pain and changes in your ECG as you exercise to your maximum heart rate. You haven’t had any symptoms because your heart isn’t challenged this way in your day to day life. The same goes for the brain.  Most of us don’t ask our brain to work at its maximum capacity, full-tilt, on a daily basis, but if we did we would see the extent of decline in our mental capabilities that have been going on since early adulthood. Tasks that require a lot a mental processing power, such as those involving quick responses and holding a number of facts in your head while making decisions, start becoming harder and taking longer in our 30s. What does this have to do with the early diagnosis of Alzheimer’s?  It turns out that while our brains are not as receptive to a quick surgical fix as our hearts (it’s more difficult to unscramble an egg than unclog a drain), the two are very similar in an important way. They develop on long trajectories of subtle but measureable changes that lead to two of the biggest killers in older adulthood: Cardiovascular disease and dementia. And though most people don’t know it, there are a number of simple computerized cognitive tests available right now that are the brain equivalent of a cardiac stress test. These mental stress tests challenge the brain to failure and offer a biomarker of your brain's aging process: They can tell if you are cognitively aging faster, slower or about as expected for your age.  While most areas of cognitive function are affected by normal brain aging, two are particularly sensitive to age and start showing changes in early adulthood. These are complex reaction time and processing speed. The testing system I use in my practice includes one for each that can indicate the onset of what’s called mild cognitive impairment (MCI)—accelerated aging of cognitive function that increases the risk of dementia. If you function well below average for your age on any of the tests, then you could be at risk for a faster trajectory towards Alzheimer’s. Hard as that might be to hear, it is something you do want to know—because there is something you can do about it. Actually a number of things, most of them familiar and hopefully already part of your life, but tweaked slightly for the brain: Exercise—both aerobic and resistance; a diet rich in anti-oxidants; reducing stress. And one more: the mental equivalent of working out at the gym. Indeed, there’s an array of cognitive calisthenics you can do that’s like the collection of exercise machines you see when you walk into the gym—everything from crossword puzzles to reading a book upside down. One book you might read upside down or right-side up is The Alzheimer’s Prevention Program, the most recent of several books on the brain by Dr. Gary Small, director of the UCLA Longevity Center, and his wife, Gigi Vorgan.  The book lays out the case for tracking how your brain is aging and how to give yourself the best chance of avoiding mild cognitive impairment and outliving Alzheimer’s. It’s ironic that the lack of treatment for Alzheimer’s has been the barrier to widespread adoption of early detection because, for the foreseeable future, the best way to avoid needing treatment for Alzheimer’s, and dying from it, is to prevent it in the first place. And there is an accumulating body of evidence that prevention is a very viable strategy. 

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