Eat your spinach! Kale?

In a study called Nutrients and bioactives in green leafy vegetables and cognitive decline: Prospective study, published in the journal Neurology, researchers wanted to measure the protective effect on cognitive decline by green vegetables.  Subjects were given a questionnaire to determine amount of consumption of spinach, collard greens, kale and lettuce.  Then they were followed for 10 years with regular assessments of cognitive function.  It was found that the highest greens consumers (114% of a serving) experienced less cognitive slowing than the subjects that consumed the least (7% of a serving.)  This effect was the same as being 11 years younger.

The authors concluded that consumption of “green leafy vegetables and foods rich in phylloquinone, lutein, nitrate, folate, α-tocopherol, and kaempferol may help to slow cognitive decline with aging.”

That can’t be so hard.  Listen to your mother!  She always knew that phylloquinone was good for you!

(Note:  If you are on Coumadin (warfarin) don’t change your intake of greens without discussing with your doctor first.  Greens also have vitamin K which lessens the effect of the warfarin and could put you at risk of a stroke.)

-DS (2-2-18)

Mid adulthood hypertension associated with later dementia in women.

In a study called Female sex, early-onset hypertension and risk of dementia, researchers followed a group of about 5600 individuals from their 30’s, 40’s and into older age.  While we know that hypertension (high blood pressure) later in life is associated with dementia, the researchers wanted to see if hypertension earlier in life also predicted development of dementia over the age of 60.  What they found was that there was no significant association between hypertension in the 30’s and dementia later in life.  But if hypertension was present in the 40’s age group, women had a 63% increased risk of dementia over women without hypertension.  The association between hypertension in the 40’s and dementia was present in women and not men.  It is not understood why this is.

The authors note theories that hypertension takes a greater toll on women, causing more kidney disease and more heart disease and these factors may lead to higher rates of dementia.  Also it was noted that more men than women died before completing the study and so perhaps men with dementia were not around to be counted.

In any event, whether the issue applies only to women or not, it does seem clear that hypertension leads to many problems, even hypertension during the younger adult years when it’s tempting to just write it off to stress or “white coat hypertension.”  We should take blood pressure seriously at all ages.

-DS (1-2-18)

Dementia avoidance: Good leads but elusive evidence.

I just came across a study by the National Academies of Sciences, Engineering, and Medicine (NAS) a body of experts that advises for governmental policy on pressing issues.  The study, called Preventing Cognitive Decline and Dementia: A Way Forward, looked at all the evidence there is on preventing dementia with certain actions or strategies.  The 3 specific strategies they looked at were 1)  brain training exercises, 2) blood pressure management, and 3) physical exercise.  The bottom line was that the researchers found that there was encouraging information about these strategies, but not enough conclusive evidence to base a nation-wide educational campaign recommending these things as ways to avoid dementia.  Sounds all-in-all disappointing, but it’s important to realize that there’s a high bar to a national recommendation from this organization.

In my view it’s interesting enough that the NAS, as well as the National Institute on Aging, which initiated the study, picked these items to review.  The scientific community believes that mental and cognitive activity can help delay the symptoms of dementia through building and maintaining cognitive reserve:  training the brain to function better like training a runner for a race.  Clinicians and scientists also believe that avoiding additional injury to the brain from blood vessel disease through exercise and blood pressure control is also beneficial.  But hard science on these things is hard to do and the high quality evidence we use for, say, testing a new drug may not be easy to come by.

While the NAS could not issue formal recommendations based on the research, they did not want to send a message that these efforts are not necessary.  In their conclusion they state:

“The subject of this report is a vibrant, dynamic research area whose story is not complete. The fact that the report does not strongly support a public health campaign focused on actively promoting adoption of any type of intervention should not be taken to reflect a lack of progress or prospects for preventing or delaying the discussed conditions. Clinical trials and other studies have yielded encouraging data for some interventions, and the public should have access to this information to inform choices on how to invest time and resources to maintain brain health with aging.”

Other areas they recommended studying for prevention of dementia were:  new antidementia treatments that can delay onset or slow disease progression, diabetes treatment, depression treatment, dietary interventions, lipid-lowering treatment/statins, sleep quality interventions, social engagement interventions, and vitamin B12 plus folic acid supplementation.

Like cognitive activity, exercise and blood pressure control, tackling any of these issues that apply to you may help delay dementia.  Even though the science is not strong enough to say it’s proved, these things are good for overall health and well-being.

-DS (11-26-17)

Respect your elders’ risk factors.

Respecting one’s elders is age-old good advice.  When it comes to avoiding stroke, younger people also need to respect the traditional risk factors that cause stroke in the elderly.  Turns out, the traditional modifiable risk factors also account for most strokes in young people.

What are the traditional risk factors?  They include hypertension (high blood pressure), diabetes, elevated cholesterol, coronary disease (angina or history of heart attack), smoking, heavy alcohol consumption, low physical activity and obesity.  These are all things you can try to avoid or treat with medication.  Just about all strokes in older people are attributed to these things.  In younger people there is the possibility of unexpected rare causes such as blood clotting disorders, injuries or tears on the arteries in the neck, cardiac defects or other genetic problems.

In a study called Contribution of Established Stroke Risk Factors to the Burden of Stroke in Young Adults, German researchers looked at 2125 stroke subjects from the age of 18 to 55 and compared them with similar aged controls without stroke.  The idea was to find out what was different about the stroke population.

From statistical analysis it was found that 4 of the traditional risk factors (hypertension, low physical activity, smoking and heavy alcohol consumption) accounted for 78% of strokes in the 18-55 age group.  Even more striking, all the traditional risk factors combined to account for a majority of strokes (56%) even in the youngest subset between 18 and 34.  In this youngest group, the risk factor that was the most significant was low physical activity.  (Facebook?  Video games?)

When I see a young person with stroke, I will always do more extensive testing to try hard to discover a cause, because stroke is uncommon in the young and sometimes we do find a treatable rare cause.  In the elderly, extensive testing is usually fruitless and we focus on the common things.  (A person is not going to discover a rare heart or genetic condition at the age of 80, for example.)

But it’s instructive to doctors to know exactly how common these traditional risk factors are in the young.  And important for younger people to recognize and respect the issues that confront our elders.  Don’t wait to get your act together with regard to exercise and blood pressure.  Don’t ever smoke and always avoid heavy alcohol consumption.  Yes, even young people can have a stroke from these things.

-DS (8-18-17)

The migraine / anxiety connection.

A recent article in the journal Headache called  Untangling the Association Between Migraine, Pain, and Anxiety: Examining Migraine and Generalized Anxiety Disorders in a Canadian Population Based Study, looked at the association between generalized anxiety and migraine headaches.

The DSM V definition of Generalized Anxiety Disorder (GAD) is paraphrased as follows:

Anxiety or worry over more than six months. This is present most of the time involving many activities.  Inability to manage these symptoms.  At least three of the following:  Restlessness, tiring easily, problems concentrating, irritability, muscle tension, problems with sleep.  Symptoms result in problems with functioning.  Symptoms are not due to medications, drugs, other physical health problems.

Sound familiar?  Just about everyone has had anxiety at some point in life, but a GAD diagnosis requires a persistent and pervasive set of symptoms.  There are also other bodily symptoms such as palpitations, chest pain, tingling and others associated with the disorder.  The study linked above surveyed around 2000 subjects with migraine and about 20,000 without migraine and  found that 6% of people with migraine qualified for a diagnosis of GAD in the prior year compared with 2.1% of the control population without migraine.  It’s not a surprising result and illustrates how problematic migraine headaches can be.  They aren’t just a bothersome headache to many people.  When migraines lead to a secondary diagnosis of GAD, it can really disable a person from living their best quality of life.

So who are the people with migraine most liable to have GAD?  People who had debilitating pain or who had problems handling their life’s responsibilities due to migraines had the highest rates of GAD, not surprisingly.  The study found some additional associations that made GAD more likely: being male, having a college degree, having low income, or lacking in a confidant.  These associations are interesting, in particular the gender association as GAD is more common in women.  It is postulated that men may be less likely to seek medical attention for migraines and therefore have worse control of the problem.

If you have or suspect you have migraine headaches, best to see a doctor that specializes in this to get the problem treated.  There’s no reason to life with debilitating headaches when there are many treatment options.  Improving headache control will likely help you avoid an anxiety condition on top of the pain in the head!

-DS (8-16-17)

Dementia rate goes… Down! (Part 2)

In a recent post, I reviewed an article about declining rates of dementia between 2000 and 2012, in which most of the difference was accounted for by increasing levels of education.  In an even longer term study based on data from the Framingham Heart Study, there was a similar finding.

The article, called Incidence of Dementia over Three Decades in the Framingham Heart Study looks at time frames starting in 1975 and divided into 4 epochs.  Over 5 years during the first epoch starting in 1975, the rate of dementia was 3.6%.  During the second epoch starting in the late 1980’s, the rate was 2.8%, then from the late 1990’s the rate was 2.2% and the 4th epoch from late 2000’s to early 2010’s 2.0%.  This steady decrease was only seen in subjects with at least a high school education.  This illustrates again the concept of cognitive reserve in which higher education is protective against dementia.  The brain may develop changes associated with dementia but the person with higher education is still able to function properly for longer.  This study also found that the negative impact of chronic illnesses such as hypertension, heart disease and stroke on dementia have declined due to better medical care and treatments in the modern age.  But this doesn’t account for all of the decline in dementia.  Something else is also playing a role, but what it is isn’t clear.

Recall that these studies are showing that individuals are less likely to become demented now than years ago, so good news for you, the individual reader.   But society in general is going to see a huge expansion in the number of people with dementia due to aging of the population and the baby boomers getting on in years.

-DS (8-11-17)

Narcotic the loser in an acute migraine trial.

A clinical trial called Hydromorphone Versus Prochlorperazine + Diphenhydramine for Acute Migraine compared 2 treatment strategies for patients with severe migraine headaches, being treated in an Emergency Department setting.  The subjects were randomized to the narcotic hydromorphone (Dilaudid) 1 mg vs. prochlorperazine (Compazine) 10 mg and diphenhydramine (Benadryl) 25 mg all given intravenously.  The trial was stopped early when it was apparent that the combination non-narcotic therapy was much better with 60% of subjects having significant reduction after 2 hours and 60% with sustained relief over 48 hours, vs. 30% and 41% given the narcotic, respectively.

In this era of intense scrutiny of narcotic use, this is welcome information and something many neurologists already suspected.  There is probably no good reason to use narcotics for severe migraine.  My preferred treatment is intravenous hydration and the non-narcotic cocktail above.  Other good options include nonsteroidals such as ketorolac (Toradol) and steroids such as decadron in the ED setting.

So if you’re unfortunate enough to be in an ED for a migraine, you might want to ask for the non-narcotic options.  They work better!

-DS (7-29-17)

North vs. South – The Nordic Diet

People in Nordic countries aren’t very fond of their southern European neighbors’ food choices.  Therefore, the highly-regarded healthy Mediterranean diet doesn’t play well in places like Denmark.  So the healthy Nordic diet was proposed, based on northern preferences and available natural foods.  The Nordic diet is comprised of high intake of fish, apples, pears, berries, cabbages, root vegetables, whole grains from oat, barley and rye and rapeseed oil.  The main differences are the focus on root vegetables, specific whole grains and rapeseed rather than olive oil.  Leading up to this recent study, evidence for health benefit for the Nordic diet has been mixed.

In a study called Adherence to a Healthy Nordic Diet and Risk of Stroke: A Danish Cohort Study, a large cohort of >55,000 Danish people was followed for an average of 13.5 years for health outcomes including stroke.  At the outset of the study, between 1993 and 1997, subjects filled out questionnaires that included diet habits and were rated according to compliance with the healthy Nordic diet.

During the study, 2283 subjects had a stroke and it was found that stroke was less common in the subjects rated highest on compliance with the Nordic diet.  There was a 14% lower risk of stroke in the highest vs. lowest Nordic diet adherents.  Authors of the paper point out that the potassium and fiber in fruits may help lower blood pressure and that flavonoids in many of the items may also promote lower stroke rates.  Other studies have shown lower mortality rates for healthy Nordic diet adherents.

The authors therefore propose recommendation of the Nordic diet especially in their region of Europe where the better-studied Mediterranean diet may be less attainable and less popular.

I think the main benefit of either diet is the avoidance of red meats, processed foods and high calorie density carbohydrates.  So get there however you can, with a Northern or Southern spin!

-DS (6-21-17)

Dementia rate goes…..Down!

In an article called  A Comparison of the Prevalence of Dementia in the United States in 2000 and 2012, authors report on data from a long-term study on dementia rates in Americans 65 years-old or older.  The main finding of this study was that in the year 2000, 11.6% of this age group had dementia and in 2012 the rate had fallen to 8.8%.  Why should this be?  Over this time course, the rates of obesity, diabetes and hypertension (high blood pressure) increased. These things should increase the risk of dementia, right?

The investigators found that the factor that most likely explained the reduction in dementia rates was higher education.  In 2000, the average level of education was 11.8 years and in 2012 it was 12.7 years.  This argues for the concept of “cognitive reserve.”  People who have attained higher education or better cognitive skills from speaking more than one language are more resistant to the decline in brain function that comes from the buildup of toxic amyloid protein from Alzheimers disease or the deterioration of brain matter from aging of blood vessels.

It’s also noteworthy that despite the fact that subjects in the later group had more medical problems such as diabetes and hypertension, better treatments exist now than 10 years ago.  And there is a strange obesity paradox in which lower weight in the elderly is actually associated with higher dementia and mortality rates.  This is probably because weight loss in the elderly usually means there’s a problem going on that reduces appetite.  In early dementia, sense of smell and taste decline possibly leading to weight loss.

Reduced incidence of dementia in individuals is only a bright spot on the bleak outlook for dementia in the US population.  For the individual person, the risk may be decreasing, but for society the problem is exploding.  The most common cause of dementia is Alzheimer’s disease, a condition with no cure.  According to data from the Alzheimers Association, 4.7 million people had Alzheimer’s disease in 2010 and the rate is expected to by 5.8 million in 2020 and 13.8 million in 2050 due to aging of the population.  We still have a lot of work to do.

-DS (6-4-17)

Improve memory with music or meditation.

An interesting study called Meditation and Music Improve Memory and Cognitive Function in Adults with Subjective Cognitive Decline: A Pilot Randomized Controlled Trial  looked at mind-body therapy for people with mild perceived memory loss.  The subjects were people who have not become disabled by cognitive loss, but have complaints about their memory, often a harbinger of future problems.  The study randomized subjects to either Kirtan Kriya meditation or music listening for 12 minutes per day for 3 months.  Compared with baseline, the participants in both activities showed improvements in overall cognition and in short term memory at the end of the 3 month intervention.  The effect even remained when the subjects were tested 3 months after that.  Areas of improvement included better subjective memory and objective improvement in attention, processing speed and executive skills or problem solving.

The authors put forth some theories about how the interventions work.   One possibility is that meditation or music listening may exert benefit by improving subjects overall sense of well-being.  Subjects reported better mood, sleep, and quality of life and less stress.  The distress that comes from perceived memory loss in itself produces worse cognitive performance and so the cycle feeds itself.  The worse you feel about your memory failure, the worse your memory failure then becomes.  It seems that maybe music exposure or meditation may help to break up this cycle.

Another theory of benefit is the understanding that music listening or meditation can actually help improve the chemical balance in the brain and improve autonomic nervous system function, all of which is beneficial to cognitive performance.  Authors also review data from other studies that show that these interventions can result in other incredible changes in the brain including reducing inflammation, promoting maintenance of chromosomes and altering gene functions that are associated with development of Alzheimer’s disease.

I was curious so I emailed the author of the study to find out what music was prescribed.  It was 12 minute selections of relaxing classical music by 6 different composers:  Bach, Mozart, Beethoven, Vivaldi, Debussy and Pachelbel.  Subjects had to sample all 6 at least once but could otherwise listen to whatever one they wanted.

So pick your preference, meditation or music (or both) and make it a regular habit.  Based on this research it could help for forgetfulness and be good for overall well-being for anyone.

-DS (4-17-17)