Lifestyle Changes to Prevent Dementia—Are We Wasting Our Time?

Lifestyle Changes to Prevent Dementia
Lifestyle Changes to Prevent Dementia

For years, we have been counselling our patients that cognitive decline may be attenuated by healthy living. The usual canards are to exercise and maintain cognitive and social activities. Recently, the National Institute on Aging commissioned five reviews of the available scientific literature which were published in the Annals of Internal Medicine, January 2, 2018. Here are the conclusions.

Physical Activity—16 Trials: Neither single nor multiple component activity showed benefit. This included aerobic, strength, resistance, endurance, and balance training alone or in various combinations. In one large study, “multi-domain” physical activity along with dietary changes and cognitive activity was possibly helpful.

Pharmacological Interventions—51 Trials: These included currently available medications for Alzheimer’s, hypertension, diabetes, hyperlipidemia, as well as estrogen and NSAID’s. Results were inconsistent between trials.

Supplements—38 Trials: These were omega-3 fatty acids, vitamins B, D, E, beta-carotene, soy, ginko, singly or in various combinations.

Cognitive Training—11 trials: Computer-based training improved results but only for the specific tasks involved. Other interventions did not show consistent results.

The point is not that nothing can work but rather that nothing so far has been consistently proven to work.

Victims of Terror Have a Higher Risk of Migraine

migraine headache trauma stress risk

It’s painful to recall the 2011 mass shooting in a summer camp in Sweden during which a lone gunman shot to death 69 teens. All of the 362 survivors were exposed to extreme terror trying to escape and dealing with the loss of friends. Among the survivors, 213 (60%) participated in a study to determine if they had a higher risk of developing headaches. Among the girls, 45% vs 13% of a control group had daily or at least weekly headaches. Among the boys, it was 15% vs 4% for the controls.

Many studies have shown an association between repetitive or daily stress and migraine or tension-type headaches. Early childhood trauma or neglect is a strong predictor as well. But rarely can a single event of extreme psychological trauma have the same effect.

What’s the mechanism? It has been known for many years that stress triggers biological changes in the hypothalamic-pituitary-adrenal axis such as increased cortisol production or activation of the autonomic nervous system. Neurotransmitters such as serotonin, dopamine and endorphins are affected as well. Even subtle daily stressors probably can cause maladaptive persistent changes, which include effects on certain genes and connectivity in brain networks that mediate pain. Now we know that a single horrific event can do the same.

See Neurology, Vol 90, page 59. Lead author is Stensland. The editorial comment is by Heyer, page 53-54.

 

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The FDA Should Approve Marijuana to Treat Spasticity in Multiple Sclerosis

Readers of a review article by Giacoppo and others in Multiple Sclerosis and Related Disorders, 2017, pages 22-31, will probably agree with this statement. Sativex is a branded oromucosal spray containing tetrahydrocannabinol and cannabidiol in a 1:1 ratio. It has been available for years in Canada and has been approved in several European countries since 2013. Combining the two compounds reduces unwanted cognitive effects.

Marijuana use for Multiple Sclerosis patients
40% of MS patients have used cannabis

This review was a literature search extending back ten years. Spasticity affects 80% of MS patients, responds poorly to currently available medications and worsens disability and quality of life. 83% of MS-Sativex treated patients had reduction of spasticity. 65% were considered responders in the first month. There was no evidence that other MS symptoms worsened. 60% continued treatment long term. Those who stopped cited lack of efficacy or side effects. 83% thought they benefited.

10%, and usually only for in the first month, had side effects, such as dizziness, fatigue, and dry mouth. Less than 1% had psychiatric side effects, including paranoia, hallucinations, panic, suicidal ideation and cognitive decline. These generally cleared with lowering the dose or stopping treatment. There was no evidence of tolerance, abuse, diversion or addiction.

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Mood Disorders in Multiple Sclerosis Can Be Caused By Neuro-inflammation

Fatigue in Multiple Sclerosis is often linked to inflammation in certain areas of the brain rather being a consequence of lifestyle factors.

Now, a study concludes that anxiety and depression in MS may be driven mainly by uncontrolled neuro-inflammation rather than by the uncertainty of living with an unpredictable disorder or the feeling of loss that comes with disability.

Subclinical inflammation is defined as new or worsening MRI activity without recognized relapses or increased physical disability.

The main finding of the study was that new MRI lesions alone were associated with increased depression and anxiety. This concerned only “state” anxiety, often a temporary condition, and not “trait” anxiety, which is persistent and reflects one’s personality or temperament.

Steroids, used for relapses, often, though only temporarily, improve mood, perhaps because they reduce inflammation in the brain.

Atrophy of the hippocampus is linked to mood disorders in patients without MS. Similarly, inflammation is detectable in the cerebrospinal fluid and in measuring cytokines in about half of patients with affective and schizophrenic disorders.

Fatigue in Multiple Sclerosis often improves when patients switch to a more effective disease-modifying drug. This may also be true for mood disorders, although this has not been studied. Could anti-anxiety or anti-depressant drugs alone help the course of MS? In support of this idea, stress management therapy was found to reduce new active MRI lesions over the course of 24 months.

See Neurology, Volume 89, September 26, 2017, pages 1338-47.

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Your Neurologist in Orange County.
Your Neurologist in Orange County.

Serotonin Syndrome – Much ado about nothing

It seems that every week a pharmacist reminds me that prescribing a triptan (such as Imitrex) with an SSRI/SNRI ( antidepressants such as Prozac) puts my patient at risk for the dreaded “serotonin syndrome.” I can imagine the incredulous patient at the counter as the pharmacist says, “Dr Florin, are you sure want me to fill both?”

This is one of a number of drug-induced syndromes that can be life-threatening. But does taking a triptan and an SSRI really increase this risk? The FDA thinks so and issued an Advisory in 2006 based on a handful of poorly documented cases.

A previous study identified 624,000 patients using both without a single case identified. This was used to support the American Headache Society’s petition to the FDA to remove the warning. But it went nowhere. Now, a new smaller study confirms that the incidence is extremely low, if it exists at all.

This dilemma is relevant because depression is common in migraine patients and the combination of a triptan and an antidepressant is often helpful.

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Your Neurologist in Orange County.
Your Neurologist in Orange County.

The Stigma of Migraine

The Stigma of Migraine
The Stigma of Migraine

Only half of people with migraine are diagnosed as such, and an even smaller number treated appropriately with triptans and still fewer are placed on preventatives.

Why should this be so? Perhaps the reason is that people with migraine believe that they do not have a real disease and may be embarrassed to seek care. They are often “stigmatized” and this leads to psychological distress, low self-esteem, and poorer social and health outcomes.

In a presentation at the 27th Annual Headache Cooperative of New England symposium, Robert E. Shapiro MD, reported on a survey of 765 people. They were given vignettes of 4 conditions that may not respond well to treatment: migraine, epilepsy, panic attacks and asthma. The respondents attributed less stigma to asthma than to the other three. No differences in the level of stigma were attached to migraine or panic disorder compared to epilepsy. This seemed surprising in that epilepsy at one point was thought to be caused by demonic possession.

Another opinion by those who completed the survey was that people with epilepsy try harder and are less likely to be malingers compared to those with migraine. Further, migraineurs who missed more work were thought to be less likely to try hard, more likely to be a malingering, less trustworthy and less likely to be interviewed for a job. There are many reasons for this stigma. Migraine is often considered to be a “women’s disease,” caused by “hormones” leading to annoyance rather than severe disability.

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Physician-Assisted Suicide and the Hippocratic Oath

Neurology center in orange county, California.
Physician-assisted suicide is sometimes called physician-assisted death.

Physician-assisted suicide is sometimes called physician-assisted death. Suicide is the more accurate word. It is not voluntary active euthanasia. This means a patient asks a physician to kill him or her with a lethal injection. In physician-assisted suicide, the physician’s act is necessary but not sufficient for the patient’s death, whereas in active euthanasia, the act of the physician is both necessary and sufficient. Active euthanasia is not legal in the United States. Physician-assisted death is legal in 6 states and DC, comprising 20% of US citizens. Opponents of physician-assisted death are fearful that it will lead to voluntary active euthanasia, as has occurred in the Netherlands and in Belgium. There, active euthanasia is done more frequently than physician-assisted-death. Furthermore, in the Netherlands, as in the United States, patients who have chronic and nonterminal diseases, including psychiatric diseases, can receive either physician-assisted death or active euthanasia.

 

In the United States, patients must be terminally ill, which is defined as a fatal disease with prognosis of 6 months or less to live. Do the Dutch value life less than Americans do? Are they less religious? Or do they believe that physicians have a duty to respect patients’ autonomy and the right to determine what constitutes their best outcome? This approach obviously conflicts with the Hippocratic Oath, which simply says do no harm.

 

In many cases, suffering, both physical and emotional, can be reduced by symptom palliation and treatment of depression. These measures would not, however, solve the problems of a patient’s financial worries, pressure from family members, health insurers, and hospitals.

 

It goes without saying that some physicians’ religious beliefs preclude them from participating, and indeed, in all states, participation is voluntary, and the American Medical Association and American College of Physicians are opposed to legalizing physician-assisted death. The American Academy of Neurology is formulating a policy, not yet available.

 

See Neurology, 2017, volume 88, an editorial with lead author Bernat. Also see the wonderful novel by Ian McEwan called Amsterdam. It is also distinguished by being short and safe to drop on your foot.

Long-Term Recovery From Traumatic Brain Injury In Children

Traumatic Brain Injury In Children
Traumatic Brain Injury In Children

A study from Cincinnati Children’s Hospital about traumatic brain injury in children followed these children up to 7 years. For mild to moderate TBI, attentional problems are twice as common. For severe TBI, they are 5 times as common and appear similar to ADHD.

 

Importantly, the home environment modifies these results. Children from disadvantaged or chaotic homes often demonstrate persistent problems, whereas those in optimal environment generally do not.

 

With effective parenting, impairment of skills that can affect social functioning might be avoided. These include information processing speed, inhibition as opposed to impulsivity, and reasoning.

 

The results of this study are important, as more than 630,000 children and teens have traumatic brain injury sufficiently severe to be seen in emergency rooms in the United States each year.

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“Chemobrain” Is Real

Chemobrain is real.

The concept of chemobrain has never been well defined. Are anxiety and depression the cause? Who is more likely to get it? Which treatments increase the risk?

 

A new study tried to answer these questions. It was published in Journal of Clinical Oncology, December 28, 2016, with lead author Janelsins. Five hundred and eighty-one patients with stage I-IIIC breast cancer with mean age of 53 years were tested before and after scheduled chemotherapy and 6 months later. Assessed were cognitive impairment, perceived cognitive abilities, the impact of cognitive impairment on the quality of life, and cognitive impairment perceived by others. Three hundred and sixty-four age-matched people without cancer served as controls. A weakness of the study is that the controls were not people with breast cancer who did not receive chemotherapy.

 

Results were that patients treated with chemotherapy reported significantly more impairment in the 4 measures described above than the controls compared to their prechemotherapy status in the immediate posttreatment period as well as 6 months later. Risk factors were higher baseline anxiety and depression and decreased cognitive reserve. The type of chemotherapy regimen or endocrine therapy or radiation therapy did not influence the scores.

 

Unfortunately, no specific therapy is available for chemobrain. Further, the risk factors identified above are so common that they cannot be used to “stratify” patients regarding a specific treatment.

 

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Your Neurologist in Orange County.

 

The Most Important Sense?

The blind would argue that hearing is more important than vision. The deaf may say otherwise. But what it’s like not to have a sense of touch?

Touch sense
What it’s like not to have a sense of touch?

Neurologists often see patients who have profound proprioceptive deficits in their arms and legs. The usual causes are chemotherapy induced neuropathy or autoimmune acute sensory neuronopathy, which may or may not be associated with a malignancy. Neuronopathy syndrome can be devastating. We can empathize with these patients, understand how disabling their disorder is, but we usually do not ask what it’s like to live without touch.

 

Jonathan Cole recently explored all of this in a book titled “Losing Touch: A Man Without His Body.” It was written in collaboration with Ian Waterman, who contracted acute sensory neuronopathy, presumed to be viral, in 1971 at the age of 19 and never recovered. He noted that for the first 12 years of his illness, no medical professional asked how it felt. One must use vision to compensate for the loss of sensory feedback. This can be mentally exhausting. For most people, walking is effortless and a wonderful time to think and reflect. Ian Waterman says, “I don’t get lost in walking. I concentrate all the way through. If I daydream, I would fall over.” If he moves his arm, he is able to return at the original position in only one of two ways: Looking at or finding the relatively warm spot where his arm was initially resting. He can feel hot and cold but is unaware of the position of his limbs. He must sleep with the lights on, and in a power outage, he is completely helpless.

 

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Your Neurologist in Orange County.
Your Neurologist in Orange County.