The skeptical cardiologist keeps forgetting that he wants to write about dementia. Does this mean he is demented?
I probably qualify as demented in the Dr. Demento sense of the word (who knew there was an archive of his playlists) but I can turn that on or off.
Since completing my cardiology fellowship training almost 40 years ago my focus has been on diagnosing and treating cardiovascular disease. I’ve always assumed that taking death from heart attacks and strokes off the table as it were would result in longer and healthier lives for my patients.
With rare exceptions these days my patients (those who are compliant with medications and work on lifestyle) don’t die or become disabled from cardiovascular disease but their lives are cut short by non-cardiac diseases such as renal failure, dementia, infections, falls, and cancer.
Like all US cardiologists I spent 3 years training in internal medicine and gained at least a basic familiarity with all of these other life-shortening areas. I pay close attention to comorbidities (i.e. noncardiac diseases) of my patients because they can impact cardiac status and medications responses.
Heretofore, I have stayed away from meddling to any significant degree (or writing about) non-cardiac diseases of my patients but as time permits I’m going to start addressing these diseases.
It is possible that I will morph into a longevity doctor during this process and rebrand myself as the Gullible Gerontologist.
Staving Off Dementia
Of those non-cardiac diseases that might impact me and my patients as we age, neurocognitive dysfunction, i.e dementia is foremost in my mind right now
My mother became quite demented in her seventies and I carry one Apo E allele (1) that puts me at higher risk for Alzheimer’s.
Clearly, I’m not an expert on dementia. If you’d like to listen to an excellent summary of the mainstream science-based PCP approach to the patient with possible dementia I recommend this excellent Curbsider’s podcast entitled “Dementia 2.0 with Anna Chodos.” It covers screening/early diagnosis, proven approaches to preserving brain health, and medical treatments in great detail.
There are, of course, a lot of quacksters, pseudoscience and profits on “brain health” supplements in the dementia space. I wrote about the total lack of evidence supporting Prevagen and other OTC supplements in 2019 (see here.) That area is still booming.
There are also respected researchers who have gone rogue and claim to have THE cure for AD. David Bredeson comes to mind. He wrote “Reversal of cognitive decline: A novel therapeutic program”
A cognitive neurologist at a large memory center introduced her critique of the “Bredeson Protocol” as follows:
my colleagues and I are often approached about the book The End of Alzheimer’s by Dale Bredesen. The book reviews his eponymous protocol, subtitled the First Program to Prevent and Reverse Cognitive Decline. The Bredesen protocol offers a plan combining several dietary supplements with detailed lifestyle changes and other targeted interventions (eg, against inflammation and toxins). The protocol has grown in popularity, even with high out-of-pocket cost to implement, and the book has appeared on many bestseller lists including those of The New York Times, Wall Street Journal, and Amazon.com. Physicians who recommend the Bredesen protocol often cite the three published studies by Bredesen, as well as his affiliations with respected academic medical centres.
Bredeson described his protocol in a 2015 article which described 10 patients. It appears to involve throwing the kitchen sink at the patient.
Discriminating readers may recognize many boring factors that everyone (including yours truly) harps on (optimize diet, reduce stress (yoga, meditation or music!), optimize sleep, exercise in this literally exhaustive list. These are things that also help you feel better and I can endorse.
But he also lists a ton of unproven supplements for various unproven contributions to dementia including ten that are designed to “optimize mitochondrial function (2)”
Dr. Hellmuth, the author of “Can we trust “The end of Alzheimer’s”? agrees with me, concluding:
There are elements of the Bredesen protocol that could be beneficial and are largely free to patients. It is standard of care in dementia clinics to educate patients, without cost, on the lifestyle interventions for brain health that are supported to some extent in the scientific literature, including aerobic exercise, a Mediterranean diet, social and cognitive engagement, and management of cerebrovascular risk factors. Health insurance generally covers testing for reversible causes of cognitive change, such as thyroid disorders, vitamin B12 deficiency, or sleep apnoea. Some elements of the Bredesen protocol that have not been shown to be effective for brain health are the intensive, costly regimens of dietary supplements. A recent international consensus document concluded that “supplements have not been demonstrated to delay the onset of dementia, nor can they prevent, treat, or reverse Alzheimer’s disease or other neurological diseases that cause dementia”.
Does The MIND Diet Reduce Dementia Risk?
The idea that a specific dietary pattern could improve brain health was supported by findings from observational studies and some evidence that links high consumption of green leafy vegetables, nuts and berries, and olive oil with a reduction in the hallmark neuropathologic features of Alzheimer’s disease.
Observational studies in nutrition are fraught and are almost always proven to be noise when tested in randomized trials..
Despite this weak evidence base, books have been written and careers based on promoting the so-called MIND diet.
Fortunately, the proponents of this diet performed a trial to see if it actually was beneficial which was published in the NEJM in 2023
This was a randomized trial of the Mediterranean–DASH Intervention for Neurodegenerative Delay, known as the MIND diet, a hybrid of the DASH and Mediterranean diets that incorporates components of the two but with modifications to include foods that had been putatively associated with a decreased risk of Alzheimer’s disease, slower cognitive decline, and fewer neuropathologic changes of Alzheimer’s disease.
The authors write:
The MIND diet, like its constituent diets, emphasizes consumption of plant-based foods, including green leafy vegetables, nuts and berries, fish, and olive oil. The diet limits the intake of foods with high levels of saturated fat and sugar, such as red or processed meat, butter and margarine, whole-fat cheese, pastries and sweets, and fried foods. Here, we compared the MIND diet with mild caloric restriction with a control diet with mild caloric restriction to evaluate the effects of a 3-year dietary intervention on cognitive decline and brain-imaging markers of dementia and Alzheimer’s disease in older, cognitively unimpaired adults at risk for dementia because of family history.
The final results showed that cognitive function and brain imaging outcomes at 3 years did not differ significantly between participants who followed the MIND diet and those who followed a control diet with a mild caloric restriction.
Does Getting the Shingles Vaccine Reduce Dementia
The skeptical cardiologist has had 3 episodes of shingles and they weren’t that bad so I had heretofore not gotten the vaccine.
Lately, however, due to two studies that were examples of “natural” randomization experiments, I began pondering getting Shingrix to reduce my chances of dementia.
My attention was initially drawn to this topic by an excellent Substack post from the always articulate and thoughtful family physician, Ryan McCormick, on his Examined Substack.
Recently, lots of Substack doctors have been posting on this including Eric Topol who was impressed by the latest study which showed a 20% reduction of dementia during 7 years of follow-up in Welsh individuals aged 80 years.
The new study is impressive and the best yet to show an effect of an outdated live-attenuated Shingles vaccine on reduction of dementia during extended follow-up. It does not, however, prove the effect is Herpes Zoster specific, a long lingering question concerning the virus’s possible underpinning role for Alzheimer’s disease, no less dementia in general. The sex differences for the two natural experiments are striking for predominance of benefit in women, which can be used to either support the vaccine-specific effect or further question what explains such marked differences.
Sadly, in this study, men did not benefit, only women.
Pulling the Trigger on Shingrix
Given my prior episodes of mild shingles on my back with no significant post-herpetic neuralgia I had felt the risks (3) of the vaccine outweighed the benefits.
An uptick in my concern about dementia given my ApoE 3/4 status changed my assessment of risk/benefits and I scheduled a vaccination at Walgreens yesterday afternoon.
Later yesterday I felt like all of my muscles and joints were more sore than usual (4) and I took 2 ibuprofen but today other than a mildly sore left deltoid I am full of vim and vigor and without vaccine side effects. No regular activities have been missed.
There is much more I could review on the topic of lifestyle changes including the 10 simple ways to improve brain health, per neurologists the NY times recently published.
I’m still on the lookout for any supplement that might forestall my brain power going down. I hope to write on one that I just started taking 3 days ago, creatine, in the near future.
Perspicaciously Yours,
-ACP
(1) My Apo E haploptype is 3/4. Those who carry 4/4 haplotype have a markedly increased risk of developing Alzheimer’s. I’ve delved deeply into this area. For a layperson-directed article with solid information read “The Burden of a Gene” published in Science. As to what caused my mother’s dementia, I have suspects. Vascular dementia tops the list because she smoked cigarettes, and developed peripheral arterial disease, coronary artery disease, and atrial fibrillation. I don’t know whether I inherited my Apo E 4 from her.
(2) Mitochondrial function seems to have supplanted metabolic function as the wellness space buzzword du jour-another hot buzzword used primarily for marketing in the wellness space that drives me crazy.
(3) CDC lists these. Of most concern to me was GBS but this only occurs in 3/1,000,000 patients, followed by the possibility of flu-like side effects which would prevent me from doing my regular activities for 2-3 days.
Shingrix causes a strong response in your immune system, helping your body create a strong defense against shingles. As a result, the vaccine may produce temporary side effects which usually last 2 to 3 day. This might affect your ability to do normal daily activities. While you may experience pain for a few days after getting Shingrix, the pain will be less severe than having shingles and complications from the disease.
Most people got a sore arm with mild or moderate pain after getting Shingrix; and some also had redness and swelling where they got the shot. Some people felt tired, had muscle pain, a headache, shivering, fever, stomach pain, or nausea. Some people who got Shingrix experienced side effects that prevented them from doing regular activities. Symptoms went away on their own in about 2 to 3 days. Side effects were more common in younger people.
You might have a reaction to the first or second dose of Shingrix, or both doses. If you experience side effects, you may choose to take over-the-counter pain medicine such as ibuprofen or acetaminophen.
Guillain-Barré syndrome (GBS), a serious nervous system disorder, has been reported very rarely after Shingrix. There is also a very small increased risk of GBS after having shingles.
(4) There is a small chance my worsened back pain, knee pain, and bilateral shoulder pain was related to playing 1.5 hours of vigorous pickleball the morning of the vaccination.
