- Healthy brain aging is important due to the rising prevalence of age-related cognitive disorders like Alzheimer's disease. - Brain aging is influenced by both modifiable and non-modifiable risk factors. Engaging in heart-healthy habits, cognitive activities, and social interaction may help promote healthy brain aging. - When discussing brain health with older patients, physicians should evaluate risk factors and encourage lifestyle changes like exercise, a healthy diet, cognitive stimulation, and social engagement.

1. Healthy Brain Aging
November 2, 2012
Brian S. Appleby, M.D.
Staff, Lou Ruvo Center for Brain Health

2. No Relevant Financial
Disclosures

3. Objectives
• Describe why healthy brain aging is
important
• Summarize current knowledge about
brain aging
• Describe ways to approach aging
patients regarding brain health

4. Healthy Brain Aging
WHY IS IT IMPORTANT?

5. 19.3% of
population

8. Rank Cause of death 2010 Age-adjusted % change
death rate from 2009
1 Heart disease 178.5 -2.4
2 Cancer 172.5 -0.6
3 Chronic lung disease 42.1 -1.4
4 Cerebrovascular disease 39 -1.5
5 Accidents 37.1 -1.1
6 Alzheimer’s disease 25 +3.3
7 Diabetes 20.8 -1
Adapted from: NVSR, 60(4)

9. 2011 Alzheimer’s Disease Facts and Figures

10. 2011 Alzheimer’s Disease Facts and Figures

11. 2011 Alzheimer’s Disease Facts and Figures

12. 2011 Alzheimer’s Disease Facts and Figures

13. 2011 Alzheimer’s Disease Facts and Figures
Dementia caregiver spouses had 6 times the
risk of incident dementia compared to those who
had spouses without dementia
Norton MC, J Am Geriatr Soc 2010

15. Work Force Concerns
• 57 new geriatric psychiatrists certified
per year
• 54/120 (45%) training spots filled per
year
• Now: 1 geri psych doc per 23,000
patients
• 2030: 1 geri psych doc per 27,000
patients
ABPN, 2010 Annual Report
Jeste DV, Psychtri News 2012

16. Healthy Brain Aging
WHAT IS IT?

17. Emery V, 2011

18. Non-Modifiable Risk Factors for
Alzheimer’s Disease (AD)
• Age
• Genetic
- PS1, PS2, APP mutations
(pathogenic)
- APOε4 roughly doubles risk (risk
factor)

19. In a Nutshell
Chronic
Diseases
Lifestyle Engagement

20. Increased risk for cognitive decline
All low level of evidence
• Low plasma selenium
• Depression
• Diabetes
• Metabolic syndrome
• Current tobacco use
Williams JW, AHRQ Publication No. 10-E005 2010

21. Increased risk factors for AD
Moderate Level of Evidence Low Level of Evidence
• Conjugated equine estrogen + • Some NSAID’s
methyl progesterone • Depression
• Diabetes
• Mid-life hyperlipidemia
• Traumatic brain injuries in
• Pesticide exposure
• Never married, less social
support
• Current tobacco use
Williams JW, AHRQ Publication No. 10-E005 2010

22. Rodrigue KM 2012

23. Vemuri P, 2012

24. Singh-Manoux 2012

25. Pimentel-Coelho PM 2012

26. Dotson VM 2010

27. Double Trouble
Diabetes and Depression
Katon W, Arch Gen Psychiatry 2011

28. Solomon A, 2012

29. Decreased risk for cognitive decline
High level of evidence Low level of evidence
• Cognitive training • Vegetable intake
• Mediterranean diet
• Omega-3 fatty acids
• Physical activity
• Non-cognitive, non-
physical leisure
activities
Williams JW, AHRQ Publication No. 10-E005 2010

30. Decreased risk factors for AD
All are low level of evidence
• Mediterranean diet
• Folic acid
• Statins
• Higher level of education
• Light-moderate alcohol use
• Cognitively engaging activities
• Physical activity
Williams JW, AHRQ Publication No. 10-E005 2010

31. Memory Fitness Program
Structure Content
• Biweekly classes • Brain health education
• 60 min in length • Memory strategies
• Lasted 6 weeks • Diet
• Given materials • Exercise
• Given homework • Stress reduction
Improved objective and subjective aspects of memory
Miller KJ, Am J Geriatri Psychiatry 2012

32. Nutrient p value
Vitamin E 0.75
Vitamin C 0.13
Folate 0.26
Vitamin B12 0.45
Vitamin D 0.75
Beta-carotene 0.78
Omega-6-polyunsaturated fatty acids 0.96
Saturated fatty acids 0.84
Monounsaturated fatty acids 0.92
Omega-3-polyunsaturated fatty acids 0.02
Gu Y, Neurology 2012

33. Ω-3 PUFA Sources
Food Correlation Coefficient
Salad Dressing 0.53
Fish 0.44
Poultry 0.30
Margarine 0.19
Nuts 0.09
Gu Y, Neurology 2012

34. Healthy Brain Aging
HOW TO APPROACH
PATIENTS?

35. Vemuri P, 2012

36. Interventions
(Delay Onset of AD)
• Evaluate current medications
• Evaluate and treat AD risk factors
• Systemic mental exercise
• Physical exercise
• Treatment non-cognitive causes of
disability
• Supportive psychotherapy
Emery V, 2011

37. Address Medical Risk Factors
• Cerebrovascular disease
• Cardiovascular disease
• Diabetes
• Hyperlipidemia
• Elevated homocysteine levels
• Head injury
• Obesity
Emery V, 2011

38. Address Trouble Medications
• Sedatives: benzodiazepine & derivatives
• Antidepressants: TCAs, paroxetine
• Antipsychotics
• Antihypertensives: reserpine, clonidine
• Anticholinergics: oxybutinin, antihistamines
• H2 blockers: cimetidine, ranitidine
• Opiates
• Corticosteroids
• Antibiotics: floroquinolones

39. Vigen C, Am J Psychiatry 2011

40. Address Neuropsychiatric
Risk Factors
• Mood disorders
• Anxiety
• Stress
Emery V, 2011

41. Address Lifestyle Risk
Factors
• Education
• Caretaker of spouse with dementia
• Environmental exposures
• Nutrition
• Substance abuse/misuse
• Smoking
• Sleep
Emery V, 2011

42. My Approach
Heart Healthy
Cognitive Engagement
Regularly Scheduled Social
Engagement

43. Heart Healthy
• “Anything associated with keeping
your heart healthy.”
• Physical exercise
• Low fat, low cholesterol diet
• No smoking

44. Physical Exercise
“Physical exercise on more days then not
for at least 30 min at a pace that you
cannot carry a conversation.”

45. Regular Cognitive
Engagement
• ANY mentally stimulating activity
- Reading
- Puzzles
- Games
- Musical instruments
• Pick what you may already be doing
• Pick what you like doing

46. Regular Scheduled Social
Engagement
• Regular: AT LEAST once weekly
• Scheduled: Combats apathy, supplies
structure
• Does not include errands or chores

47. • Disease
• Life Story
• Dimensions
(Personality)
• Motivated Behaviors

48. References
• Dotson VM, Beydoun MA, Zonderman AB. Recurrent depressive
symptoms and the incidence of dementia and mild cognitive
impairment. Neurology 2010;75:27-34.
• Emery VOB. Alzheimer disease: Are we intervening too late? Pro.
J Neural Trans 2011;118:1361-1378.
• Gu Y, Schupf N, Cosentino SA, et al. Nutrient intake and plasma
beta-amyloid. Neurology 2012;78:1832-1840.
• Jeste DV. Aging and mental health: Bad news and good news.
Psychiatr News 2012; 4:3.
• Katon W, Lyles CR, Parker MM, et al. Association of depression
with increased risk of dementia in patients with type 2 diabetes:
The Diabetes and Aging Study. Arch Gen Psychiatry 2012;69:410-
417.

49. References
• McHugh PR & Slavney PR. Perspectives of Psychiatry. The Johns
Hopkins University Press, 2nd edition, 1998.
• Miller KJ, Siddarth P, Gaines JM, et al. The memory fitness
program: Cognitive effects of a healthy aging intervention. Am J
Geriatri Psychiatry 2012;20:514-523.
• Norton MC, Smith KR, Ostbye T, et al. Greater risk of dementia
when spouse has dementia? The Cache County study. JAGS
2010; 58:895-900.
• Pimentel-Coelho PM & Rivest S. The early contribution of
cerebrovascular factors to pathogenesis of Alzheimer’s disease.
Eur J Neurosci 2012;35:1917-1937.
• Rodrigue KM, Kennedy KM, Devous MD, et al. Beta-amyloid
burden in healthy aging: Regional distribution and cognitive
consequences. Neurology 2012;78:387-395.

50. References
• Singh-Manoux A, Czernichow C, Elbaz A, et al. Obesity
phenotypes in midlife and cognition in early old age: The
Whitehall II cohort study. Neurology 2012;79:755-762.
• Solomon A, Kivipelto M, Soininen H. Prevention of Alzheimer’s
disease: Moving backward through the lifespan. J Alzheimer Dis
2012 [In Press].
• Vemuri P, Lesnick TG, Przybelski SA, et al. Effect of lifestyle
activities on AD biomarkers and cognition. Ann Neurol 2012 [In
Press]
• Vigen CLP, Mack WJ, Keefe RSE, et al. Cognitive effects of
atypical antipsychotic medications in patients with Alzheimer’s
disease: Outcomes from CATIE-AD. Am J Psychiatry
2011;168:831-839.