ZACH: Welcome to On Health with Houston Methodist. I’m Zach Moore. I’m a photographer and editor here, and I’ve worked in multimedia and television for over 15 years, and I’m also a longtime podcaster.

TODD: I’m Todd Ackerman. I’m writer, editor, who previously covered science and medicine for the Houston Chronicle.

ZACH: And Todd, dementia can be a scary word, right?

TODD: Well, it certainly is to me. I would say it’s my number one fear among health ailments as I get older.

ZACH: Really?

TODD: Yeah.

TODD: You know, a lot of the topics that we cover, I’m kind of a killjoy at saying, well, I’ve never really experienced this. But for this one, both my parents had dementia. I don’t really have a family history of -- Say cancer. So, that’s kind of my most feared disease.

ZACH: Presumably, when they were older, they developed dementia?

TODD: Yeah, I mean, they had a good run, they made it to 92, and it was very late stage development. My watch firsthand as in -- When they both hit about 90, they started to lose it, and it was tough. Tough for them and tough caring for them as well.

ZACH: Yeah, I mean when you think about all the potential health problems you can encounter throughout your life, and especially getting older. Dementia is especially concerning because you kinda lose who you are, right?

TODD: Yeah, exactly. To me, like, your memories are who you are. My dad before he got it -- I never heard him say this, but my brother told me. He said he used to describe Alzheimer’s as living death. And it seems to be a fairly apt description of it.

ZACH: Yeah, my grandfather lived to 92, and started to develop early stage dementia, but that almost -- And we’ll talk about how this all works in our podcast today, but it was more of a side effect of him just getting older. You know, it wasn’t like a dementia diagnosis, per se. So, he had some of the side effects of -- Like he never forgot who He was or anything like, but you know, getting this loops of repeating the same thing over again. Asking what day it is, or watching some sports game. “Hey, what’s the score?” Stuff like that, right? So, those kind of low level, if that’s even terminology for dementia, but that’s the extent of my personal experience, with dementia, fortunately, so far in my life.

TODD: Yeah, that’s not dissimilar from how it worked with my parents. My dad was doing great, and then we brought him to his doctor saying we were concerned about some memory issues and behavior issues, and he gave him the oral test they give. He did great on it except for anything time related. He had no concept of time whatsoever. So, the doctor told us, it was just age-related decline, but then he gave him Aricept, which is the dementia -- The Alzheimer's drug. And my dad kinda held steady for a year, and then he went downhill kinda fast, and it was pretty clearly Alzheimer's symptoms at that point. So, my mom was kind of similar, she was in pretty good health until like, when she was 82, she got Shingles and never got over it. She died ailing in pain from Shingles, but she was pretty much bedridden because of it. She was on pain killers for it, and that kinda knocked her and so, her heart declined. Both my parents were in heart failure -- Or had heart failure. By the end were in heart failure. I always thought that their dementia was kinda caused by poor blood flow, which we’ll be talking about during the podcast.

ZACH: Well, thanks for sharing that, Todd. I can understand hearing that why dementia would be such a great health concern of yours and why you’d wanna learn about it.

TODD: Yeah, I would say I have a pretty keen interest at this point in dementia prevention. I read anything I can on the subject and try to do whatever I can. I certainly, exercise, and healthy eating are the first things people mention, but I’m always interested, if there’s anything else that might give me an edge.

ZACH: And to that end, who did we talk to today, Todd, about dementia?

TODD: We talked to Dr. Gustavo Roman, who is a Houston Methodist neurologist, who specializes in memory problems, Alzheimer’s disease, other forms of dementia. Unlike some people he does not shy away from the term dementia prevention, and he gave me some papers of his when – Where he used the term dementia prevention in title.

ZACH: Is that a terminology people shy away from?

TODD: Well, I think there are some views that, you know, a lot of it is so genetic. If you’re programmed to get it, there’s not a lot you can do.

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TODD: So, we’re here with Dr. Roman. Dr. Roman, good to have you.

DR. ROMAN: Thank you very much for the invitation.

TODD: We’re here to talk about dementia and dementia prevention. What people can do to reduce their risk. First of all, what are the numbers of people with dementia these days. How deep into this tsunami, I’ve been reading about for the past 15 years or so, where are we with that?

DR. ROMAN: It’s becoming a bigger and bigger problem. The name tsunami, I think tells us very clearly what it is. Here, we have a clinic that is dedicated to seeing only patients with memory problems, and problems with dementia. And the appointments keep getting longer and longer. The waiting time, because of the increase in the number of cases. This is probably the result of what has been called the grey hair laws, that you see an increase in the number of people over the age of 65. It is said that 1 of every 10 people over the age of 65 is going to develop dementia, and the figures that are given by the Alzheimer's Association indicate probably there are 6 million people with Alzheimer's disease in the United States and doesn’t sound like too much, but it’s a combined population of Houston, San Antonio, and Dallas. So, 6 million is a fairly large number. The problem is that the number of cases of dementia tends to increase as you get older, so by the age of 85, you may have 1 out of 3 patients developing dementia. So, aging is the main risk factor for this, and the population again, is increasing. The fastest group of age in the United States are the 85 and older. So, that explains why is it that we see so many patients complaining of the memory difficulties and the problems with dementia.

TODD: To cut to the chase here, can people prevent dementia, or is it in your genes, you’re just unlucky. It’s your family history, and there’s not a lot you can do about it in those cases.

DR. ROMAN: I think it’s a little bit of both. There is a contribution from the genes, from the family history. In most situations, where either mother or grandmother, or someone in the family had Alzheimer's disease, we don’t have a clear gene that is sort of the – If you get the gene, you’re gonna get it. These increase the risk by 10, 15%. So, if you have a gene, especially the one called APOE, you increase the risk of developing dementia. So, you need to be careful in trying to plan of how you can beat that inheritance that you have. But in the large majority of cases that we see here. There is either no family history, or the family history is so remote that you cannot really blame that for the development of the disease. So there must be a number of the environmental factors, what is called the genes that are influencing the expression of genes. This is something that the oncologists discovered many years ago for the treatment of cancer. That giving vitamins for instance, you can control the expression of those genes. It’s called the – Especially with the folic acid, you can prevent the expression of the genes that are gonna produce cancer. So, we’re looking in the same direction, trying to decide what are the products that can actually limit the factors that leads to the development of dementia.

TODD: You mentioned that it’s 1 in 10 at what? 65?

DR. ROMAN: At age 65.

TODD: At 85, it’s 1 in 3. If you live long enough, is it almost inevitable that you’ll get either Alzheimer's, or some significant cognitive impairment?

DR. ROMAN: Yes, indeed. That’s a very good point because when you look at the brains of centenarians for instance, people who may or not – May not have been having any cognitive problems. The changes in the brain are those of Alzheimer's disease. So, that an accumulation of Beta-Amyloid and tau proteins, neurofibrillary tangles, that are the changes that you see in Alzheimer's disease. The difference then is that those changes were not sufficient to produce dementia. So, from the morphological viewpoint, if you look at the brain, there are changes that tell you, yes, somehow, this is linked to aging and is going to be manifested. And the things that, in a way, protect you from that include, in the first place, what is called the cognitive reserve. And that cognitive reserves is in a way that if you have been building connections in the brain from learning another language, from studying a particular area, when you do that, you are increasing the connectivity of the brain. So, if you have a good cognitive reserve, you have built in your brain enough connections, that you can spare a few without going into dementia. And this is part of the plan to try to prevent dementia from being expressed and realized.

TODD: So, before we get to what people can do, let's define our terms a little bit here. Dementia is an umbrella term for a number of different degenerative brain disorders.

DR. ROMAN: Yes. Dementia comes from the Latin that means no mind. So, when you tell someone that Grandpa is out of his mind. That's a correct definition, you lost the mind that is the product of the function of the brain. So that Grandpa who used to be a very gentle person, very nice with the family, all of a sudden, becomes more angry, more agitated, doesn't recognize the family, cannot find out the right words when he's talking. And he seems to be repeating the same questions over, and over. And he starts losing the capacity to take a shower, to brush their teeth, to control bladder and bowels then it's a different person. So, it's out of his mind, and that's what the word dementia means, "De" without and "mentis" is the mind.

TODD: Is vascular dementia the one you can most reduce the risk of?

DR. ROMAN: Oh yes, indeed, the vascular dementia can be treated, essentially, because of the advances in cardiology and endocrinology. If you are able to control, to diagnose early and control your blood pressure, you are ahead of the game. That certainly protects the brain from having the problems of multiple, little strokes related to high blood pressure. And there are a large number of medications that are extremely efficient for the treatment of hypertension. We also know that avoiding too much salt in the diet is a factor that helps you control the blood pressure. The same is true for high cholesterol particularly, recommending, the Mediterranean diet with plenty of fish and seafood, fruits, and vegetables is quite helpful in lowering the levels of the bad cholesterol. Low-density cholesterol that can contribute to blockage of the arteries, including arteries in the brain producing strokes, and problems with cognition. We have also found that the lack of vitamins in the B group increases amino acid, that is very damaging to the blood vessels, increases the risk of heart attacks, and increases the risk of stroke and in that way, by giving the appropriate B group vitamins you can lower that factor and decrease the risk of the vascular component of dementia. But you're right the from the vascular component, there is really no excuse for not being able to treat this -- These major conditions.

TODD: Are there lots of people with some sort of cognitive impairment that fall short of those categories? You can see the person is affected, but they don't really fit a diagnosis yet?

DR. ROMAN: Yes, indeed. And that's -- Before you get to the definition of dementia where in clinical terms, you tell that a person has dementia when the person loses their independence. Needs help to get pills, to get dressed, can no longer drive. So, the loss of independence secondary to Alzheimer's disease or one of the other dementias, is sort of the frontier. From that point on you’re dependent and that is dementia. Before that, we talked about mild cognitive impairment, and it comes in many categories. The most frequent one is, of course, the short-term memory deficit, the patient who keeps asking the same questions, who is told once, and twice, and three times, and five times that “No, we are not going to go to supermarket today.” So, this short-term memory is not enough to get the patient incapacitated, or dependent on the family. So, he has mild cognitive impairment or MCI, and that's the category that we were -- We essentially would like to see the patients because things are just beginning and at that time, we can see what are the risk factors that can prevent going from MCI to dementia.

TODD: How much age-related mental decline is to be expected, you know, you I think of athletes and how they start losing their abilities around 35, maybe by 50, they'd be a shadow of themselves. Is that some same sort of thing going on with the brain?

 

DR. ROMAN: Absolutely. Absolutely. And we all go through the problems of finding, where did I put this thing or going from one place to the other and say, "What the heck am I doing here? I don't remember.” Then you go back, and say, "Oh, now I remember." There are difficulties also with verbal expression. The difficulty with what we call word finding difficulties. Trying to find the right word is on the tip of my tongue, trying to remember the last name of a person that you just met. They say, "Had on the tip of the tongue." Those are problems associated with aging and in a way, they are more related to the blood vessel problems that in a way, affect the areas of the brain that work as the highways that connect one part of the brain to the other. This is called the white matter. You have on the outside, the gray matter, the convolutions of the brain. And all that gray matter that is affected by Alzheimer's disease is connected to different parts of the brain through these highways in the white matter. And when you have problems with arterial hypertension or little strokes, those are the areas that are affected. So, instead of having a very fast highway that allows you to go from one place to the other and come up with the right name or the right explanation, you take a little longer to send the message in the right place. And one of the factors that we have not mentioned, but that is quite important for hypertension is a good night of sleep. People who snore, and more than snoring, who stop breathing and have what is called obstructive sleep apnea during sleep are at a high risk of developing this white matter issues because when you are not breathing at night, the brain triggers an alarms that say, "Hey guy, you got to breathe. Take a deep breath."  And since the door is closed here, because the tongue falls back and blocks the airway, then the low oxygen essentially triggers an alarm. An alarm in the brain is adrenaline that gets your blood pressure and your pulse high and wakes you up. Not to the point to wake you up and say, "Hello, how are you?" But enough to go from deep sleep, the rapid eye movement or REM sleep. And during that time the brain is really cleaning all the leftovers from the metabolism of the day. So, if you don't have a good night of sleep because of sleep apnea, you're not having enough REM sleep, to clean the brain. And you're having a constant burst of high blood pressure that are not good for the heart and the brain. So, this is becoming also, a very important factor in the prevention of dementia from Alzheimer's disease.

TODD: So, can you give a kind of quick lay-friendly explanation of what exactly happens in Alzheimer's. I've read a lot about the build-up of plaque in the brain. I guess, Tau it's called and the other thing I hear is that the brain shrinks. Are those both good ways to think about it?

 

DR. ROMAN: Yes, indeed. Again, we don't know what is it that triggers this process. But aging is an easy way to sort of summarize what is happening. And what is happening is that the brain, especially the neurons in the gray matter, in the cortex of the brain. Those are the ones that build these connections when you are learning something. Those connections are lost and then the brain is also depositing abnormal proteins. The most frequent one is beta-amyloid. That's the one that has being targeted by the pharmaceutical industry. The two new products that we mentioned that have been approved by the Food and Drug Administration, remove the amyloid from the brain. Although until now, without any major effects and improving cognition, and so on. And the reason for that may be that the second component, which is the Tau protein, that produces sort of changes in the structure of the of the brain is called neurofibrillary tangles. Those changes end up disconnecting the neuron. So, all this connectivity in the brain, all these connections that you build with so much difficulty during elementary school, middle school, high school, college, all these connections in the brain tend to disappear when that happens. Then the brains begins to shrink because these neurons actually die, they disappear. And as the number of bodies in the in the gray matter disappears, then there is a shrinking of the brain. That shrinkage of the brain is compensated in part by increasing the amount of fluid in the brain, the water, and that can lead to another form of dementia called normal pressure hydrocephalus or NPH, which is one of the few forms of dementia that we can treat effectively with the help of neurosurgeons and other treatment.

TODD: So, dementia is a process in which the symptoms are only exhibited, say 20 years after the process starts, right?

DR. ROMAN: Absolutely.

TODD: Are there brain tests a seemingly healthy person can take to learn if he or she is on that path?

DR. ROMAN: There is a strong development trying to measure in the in the blood, the levels of beta-amyloid and Tau protein. In that way, you could -- years ahead of the of the game. You can make a diagnosis just with a blood test, but we are still far away from that goal. So, --

TODD: How about scans?

DR. ROMAN: PET scans are quite useful. PET stands for Positron emission tomography. So, in that case, they have to inject in intravenously sugar, glucose that is tagged with an isotope of fluoride and the brain uses the sugar to produce energy. So, you can actually map what parts of the brain are using the glucose, the sugar in the appropriate way and what parts are lagging behind and not -- They have what is called the hypometabolism. The amount of energy that is being produced by these sugar in the brain is limited to some areas that are the ones that have to do with memory for instance, or with language, in the case of the frontotemporal dementias. Or in some cases vision loss, patients, who start having difficulty with vision, and they go from one pair of glasses to the other and nothing works. So finally, someone said, well maybe the problem is not in the eyes, could be in the centers of the brain that analyze the vision. And that is something that the PET scan can diagnose with accuracy. There are also -- And we are beginning to develop tests that measure how much amyloid is deposited in the brain and how much of the Tau protein is present. So yes, we can do the imaging. The only problem is that these are quite expensive tests and the insurance companies in general are reluctant to do that, unless the patient has a confirmed diagnosis of one of these forms of dementia frontotemporal, or Lewy body or Alzheimer's disease.

TODD: Are many people typically taking those tests pre symptoms?

DR. ROMAN: Very little, unless you're part of the of a study, the tests are not done.

TODD: Should that change, you think?

DR. ROMAN: Hopefully it will change but what we do have is the neuropsychology testing and those are quite good. There are a number of tests that you can do that check your capacity, or the parts of the brain that are responsible for different functions. For instance, one of the most popular tests is the clock test. They tell you please draw a clock, big circle. Put all the numbers on the face of the clock and then put the hands so that it reads, whatever, 11:45. And that simple test actually is checking how is the frontal part of the brain that is in charge of what is called executive function? This is sort of the board of directors of the brain that tells you how you drive your car, how do you get dressed, how do you take care of cooking. All these things have been learned and they are controlled by these frontal part of the brain. And that's why people who have the frontotemporal dementias have so much difficulty with life, they lose control of these functions that are normally quite -- Even think about that, because the board of directors in the brain, the frontal part, is in charge of the executive function and that usually is quite effective in keeping you active and doing the things that you learn without difficulty.

ZACH: Dementia is not a specific diagnosis on its own, rather, it's a general term for any severe decline in mental abilities, due to the brain’s physical deterioration. Here are the four most common types. Alzheimer’s disease, the most common type of dementia, Alzheimer's is diagnosed every 67 seconds, according to the Alzheimer's Association. A progressive disease that leads to broken connections between nerve cells and tissue shrinkage in parts of the brain. It is the country's sixth leading cause of death. Former President Ronald Reagan drew attention to the disease in 1994, five years after leaving office, when he announced in a letter to the American people that he'd been diagnosed. Vascular dementia, probably the second most common variety of dementia. Vascular Dementia is caused by reduced blood to the brain, often the result of mini strokes. Symptoms vary depending on what brain region is affected. But many include short-term memory problems, getting lost in familiar areas, inappropriate laughter, or crying, trouble following instructions, difficulty concentrating, lack of bowel or bladder control and hallucinations. Considered under-diagnosed it's thought to account for 15 to 25% of all dementia cases. Lewy body dementia considered the third most common dementia, Lewy body involves protein deposits developing in nerve cells in the brain regions involved in thinking, memory, and motor function, characterized by hallucinations and trembling, in addition to symptoms like memory loss, it can be confused for Alzheimer's and Parkinson's or combined with it. The late actor, Robin Williams was diagnosed with Parkinson's a few months before his 2014 suicide, then with Lewy body following an autopsy on his brain. Frontotemporal dementia, the least common of the four main dementia types, frontotemporal disorders are the result of damage to neurons in the frontal and temporal lobes of the brain. Region’s key to maintaining skills related to memory, language, judgment, problem solving, and behavioral, and emotional regulation. Last year, actor, Bruce Willis, was diagnosed with the condition, not long after his family announced he had Aphasia, a disorder that affects the ability to communicate. Frontotemporal dementia is a progression of that condition.

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TODD: We'll have more with Dr. Roman after the break.

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TODD: Now, back to our conversation with Dr. Roman. So, when's an appropriate time for people to start thinking about what they can do to reduce their risk? I know the answer is probably, “it's never too early to start”, but realistically, I doubt people in their 20s, 30s, 40s are really thinking about that. But how about say, people in their 50s, they're in good health, they feel mentally sharp, but they just saw their parents diagnosed with dementia, or they're exhibiting some sort of cognitive decline. Should those people start saying, “Hey, what can I do so that I don't go down that path?”

DR. ROMAN: Absolutely, you're absolutely right. Especially when the disease kind of touches very close to where you are. You know, if you are in your 40s, I think it's a good idea to make sure that you check your blood pressure, your cholesterol, your vitamins, and that you do some of these very simple cognitive tests that are available on your cell phone. I mean, if something is not looking good, then you check with your primary care physician, with your family doctor, who will decide if there is a need for, for either replacement of the vitamins, could be as simple as that, or adjusting your blood pressure medication, or making sure that you don't have obstructive sleep apnea. Because these are things that can be treated and that are quite effective in preventing the progression of a gene from neurodegeneration.

TODD: Are you pretty familiar with the sort of category I mentioned? Somebody in their 50s who is seemingly in good health, feels mentally sharp but they see their parents get diagnosed or exhibiting symptoms and they wonder what they can do. Do you hear that a lot from people?

DR. ROMAN: Well, yes, yes, of course, yeah. And again, that’s part of the reason why we’re having this conversation today. That people need to learn that there is a number of things that you can do to either slow down or even to really halt the progression of this conditions, but you need to do it early enough, so by all means, yes, indeed. And in general, the general practitioners, the family practice are quite aware of the things that you need to look for in someone who has this history of perhaps inheriting a gene that has been associated with Alzheimer’s disease.

TODD: I assume most of all of your patients are people that either have dementia, or they’re coming in concerned about ‘cause a family member has noticed a change or something. Are the latter group that are just starting to exhibit symptoms --

DR. ROMAN: Yeah.

TODD: Are those the candidates for prevention strategy?

DR. ROMAN: They are beginning to -- I think the population in general is beginning to realize that you don’t have to wait until you’re totally incompetent to be able to be treated for these problems, so we are seeing a larger number of patients and that also has been a blessing in the sense that now we have people with very early forms who have mild cognitive impermanence, I mentioned, who are at risk of progressing to Alzheimer’s disease, who are willing to participate. Who are candidates who made the criteria for this mild cognitive impermanence, early treatment of these conditions. Yes.

TODD: So, this seems like a good time to segway into, you know, what the risk factors are and what people can do. Let’s start with risk factors. Besides aging and family history, what are risk factors?

DR. ROMAN: We have been mentioning the vascular risk factors. Those are certainly very important. Hypertension, diabetes, hyperlipidemia, problems with cholesterol, problems with cardiac arrhythmias. History of heart attacks, all those are risk factors that essentially increase the risk of worsening the mild cognitive impermanence getting into dementia.

TODD: Gender is a risk factor? Women get it more than men?

DR. ROMAN: In the sense that women are more affected than men and that’s one of the mysteries. We don’t know why. Usually, women, oddly men in general in the population, but they are at higher risk of developing Alzheimer’s disease, so something with the hormones. And some of the trials for the use of hormones post menopause found that some of those hormones actually were associated with increasing the risk or speeding up this cognitive decline. So, there has been a, in a way, it tends to stay away from female hormones post menopausal because of the increased risk of vascular legions and of course increase risk of Alzheimer’s disease and dementia.

TODD: And smoking and more than moderate drinking?

DR. ROMAN: Smoking certainly is a risk factor in part because of the effects that the smoke will have on the lining of the blood vessels. So, people who smoke tend to have problems with occlusion of the femoral arteries. They have intermittent claudication. They cannot walk because the deposit of cholesterol in the large arteries, but the same thing happened in the brain. So, smoking certainly is a big one. It’s a major risk factor. And nowadays people tend to realize that it’s perhaps not a good idea. In terms of alcohol, I tell the patients, “Well” -- They say, “Well, I just have a maybe a little glass of Scotch or something at the end of the day to relax. There are some days where I don’t drink anything. Or I’ll have a glass of Chardonnay or red wine with dinner. I think I learned that in Europe they do that every day with breakfast, lunch, and supper, so I think it’s probably good idea. It’s good for your brain and so on.” Well, I tell them that you probably heard that people drink to forget. Well, it works. So, alcohol and memory don’t get along too well. Not only because of this increased consumption of the thiamine, the B1 that can produce a dramatic loss of memory and produces dementia, but also because one of the things that usually happens is that, since your memory is not that good, you really don’t know if you had a glass of wine or not and by the end of the day, half of the bottle is gone and you find yourself consuming more alcohol and more wine than usual. So, I usually advise the patients with mild cognitive impermanence to avoid alcohol completely if they can do it. So, it’s a very controversial area. Some of the studies that were done in Europe demonstrated that the drinking just a glass of wine with breakfast, not breakfast, with lunch and supper had some positive effects in memory, preventing the age associated cognitive decline.

TODD: Obesity.

DR. ROMAN: Absolutely. And then, we get into the problem that is a significant problem here in the United States, which is the problem of obesity. Not only it increases in a major way the risk of developing diabetes, you have what is called insulin resistance in people who gain an increased amount of weight, but also it means that you’re not doing your exercises, that you are very sedentary, and also that you increase the risk of developing of obstructive sleep apnea with all the consequences that it has on preventing you from the good part of sleep. So, in a way, a good night of sleep is a factor that decreases the risk of developing Alzheimer’s.

TODD: I read that research is suggesting about 40% of Alzheimer’s cases may be preventable based on modifiable risk factors. Do you agree with that?

DR. ROMAN: Oh certainly, yes. And the earlier you see them, the higher the percentage will be of course, because once you reach a certain point where there has been this major sort of devastation in the brain with shrinking, and atrophy,  and then there is very little you can do to regenerate those areas. Again, it was very difficult in the first place to create those connections, those synapses in the technical term. The synapses are the connection between the neurons and actually get enough of these circuits to learn, to speak a foreign language, or to play an instrument. All this seems to take a lot of effort, so once they -- those areas are destroyed, they are not gonna come back.

TODD: Let’s talk about things that you might emphasize. Are diet and exercise the first things?

DR. ROMAN: Yes, indeed because you need to realize that maybe the diet that you’re having is not the safest for your brain health. But the consumption of excessive amounts of cholesterol is another point. If you survive on hamburger and fries every day, you are actually getting too much of these fatty products, so it tends to produce products that are not healthy for the brain and for the blood vessels. So, what we are recommending, because of the experience from trials where you actually look at the natural situation of people -- in for instance a seven city studies compared the diet from Finland, Holland, with Crete and Greece, with Japan, and there was an order of magnitude, bigger number of cases of heart attacks and death in these areas that consume a lot of milk and meat compared with the diet in Greece or in Japan that eats a lot of fish and very little in the way of red meat. They also tend to have a diet that relies on green leafy vegetables. And in Crete in Greece who has the record for the healthiest diet, extra virgin olive oil certainly is a factor that seems to help control the bad cholesterol and it has positive effects in prevention of diabetes and some cognitive effects that certainly are quite important. So, we are becoming fans of the Mediterranean diet. In Texas, it’s a little bit difficult because you’re used to steak and potatoes. So more and more people are essentially learning that at least having fish once a week is a good thing for your health. The other thing that has been found is that if you eat more than three different types of fruits in a day, your risk of heart attacks and dementia decreases significantly. And the same is true from the red color that you see in seafood, in lobster. They feed on a microorganism that produces something called astaxanthin which is probably the, nature’s strongest antioxidant that will help you sort of fight the normal, excitatory problems that you get with the things in the environment. The cars, and the chemicals in the air that you are exposed to. So, this Mediterranean diet has these factors.

TODD: And then, sort of counterintuitively, the best thing you can do for your brain health is physical activity, exercise?

DR. ROMAN: Yes, indeed because of perfusion, the amount of blood going to the brain, is gonna depend also on how active you are. When you go out walking fast for a couple of miles, when you go to work at the gym, or do this anaerobic exercises, you are actually stimulating also the circulation in the brain. This is also good for once the body temperature increases with the exercise, that in itself is an antioxidant function. You are fighting infections. You are fighting a number of these oxidative products that you are receiving during life here in the city or living close to the highway. All these things certainly have been found to have a deleterious effect on cognitive function. And can be improved with regular exercise. And again, you don’t have be lifting a large amount of weight, but walking, stationary bike, all these things are okay. If you like to ride you bike or if you want to ride a horse, you need to put a helmet of course because head injuries are a cause of dementia, and you may fall and if you don’t have the appropriate protection for the head that is also a risk factor for dementia.

TODD: Brain puzzles, exercises, there’s not a lot of evidence proving that they stave off dementia.

DR. ROMAN: Well, they certainly help you remain at the level you are. It is important to do that, crossword puzzles and all these games that you find now on the internet are quite good. The best pushups for the brain actually include speaking a foreign language. Those are probably one of the best exercises for the brain. There was a study done in Canada some years ago where they compare the cognitive decline with, they chart how well you do as you grow old when you speak just one language, either English in Canada or French for area of Montreal, the Quebec province, or when you compare that with people who are fully bilingual, who spoke English and French. Well, there was no difference, no gain. The ones who were bilingual were ahead of the game but a major distance. So, if you learn any of those languages in, when you were in high school or college, one of the best ways you can do is start practicing that and trying to speak. Practicing another language is the best exercise we can get. The other exercise that is quite good for the brain is playing a musical instrument. You -- If you took piano lessons when you were, early in life and you can still kind of read it but forgot how to do that, that’s an excellent exercise because you are increasing the capacity of concentration. You’re looking at the notes, you have to know what finger to use and what, is the sound that you should get, and you are constantly in this sort of circuit that essentially increases your attention. So, playing an instrument is also something that is quite helpful. The same is true for doing some artistic things. I usually keep some of the art forms that patients have said they, “Well, bring me the homework next time I see you.” And they really do very good. And again, by the same reason, you are just looking at the shadows on the apple, or whatever it is as you are drawing and that increases a sense of attention, and it gives you the sense of creativity. You are accomplishing something that in a way takes you away from the fact that your short-term memory may not that good. So, those are the main areas that are helpful to work as pushups for the brain as we call them.

TODD: And social engagement generally, I assume.

DR. ROMAN: Yes, during these past years with Covid where we had, especially when we had the lockdowns, and we had essentially no social interaction, it was really a major factor in causing deterioration and dependency.

TODD: You actually saw that in your patients?

DR. ROMAN: Yes, of course. They had to stay home. They couldn’t see anyone. Their family couldn’t visit. And the decline was much more significant. So, social interaction is very important. We are social animals and many of my patients keep -- get into the groove where they play Bridge, or they play Poker, or, those are good because you’re enhancing your attention. You need to know what cards you’re dealing and what could be the other card. So, all those are really quite effective ways of enhancing your cognition.

TODD: And so, I’ve read that being attentive to hearing issues is a big thing. If you need a hearing aid, that’s vitally important to prevent Alzheimer’s. Can you explain that to me a bit?

DR. ROMAN: It has been found that indeed hearing loss, of course very common in our patients, is a major factor. The problem is that many of them are reluctant to use a hearing aid. It’s also very common in veterans, especially the ones who saw action and were exposed to high noise from artillery and that sort of thing, or people who work in a high noise environments, they tend to lose hearing quite commonly. And that essentially can be controlled of course with the appropriate hearing aids, but it’s a major factor in the social interaction. They are essentially excluded from the conversations in a group because they just don’t know what they are talking about or when they say something, it has nothing to do with what the topic of conversation was. So, it is very important. It's quite common. We see this very, very often. And now, using the face mask in the clinic, the patients used to kind of be able to read, kind of learn what you were saying but if your face is covered, they just cannot know what the conversation is all about.

TODD: So, let’s talk about any vitamins or supplements you could take. You mentioned the B vitamins. That’s B6, 9 and 12?

DR. ROMAN: That’s correct. Yeah. The data that we have is fairly solid. This is the result of what is called a controlled clinical trial. What they did in England was to take people with a diagnosis of mild cognitive impermanence. They gave these group of vitamins in the B group, B1, B6, B12, and Folic acid, and they let them sort of go home and take their medications. There were controls over time to make sure that they were indeed taking the medication or the placebo. And then, at the end of the trial, they repeated the PET scan to see how much of these lack of mentalities the brain was having from development of what was considered to be earliest form of Alzheimer’s disease. And the trial was very conclusive. People who were taking the vitamins compared with the ones that were taking just the placebo, that’s the sugar pills, had stopped the progression of the problems. The scores were the same compared with the others who had continued to decline over the period of two years, and the decline was explained by the increase in the areas of the brain that were not able to use the sugar, so. They also measured a product called Homocysteine which is an amino acid. It’s sulfur-containing. It has a group of sulfur that is very nasty on the lining of the blood vessels and tends to produce an increased risk of coronary disease, and heart attacks, and strokes. So, the Homocysteine had decreased quite a bit in the ones who were taking these vitamins. So, the conclusion was that if you take these group of vitamins early enough, you’re able to slow down in a significant way, and sometimes you’re able to really stop, you really can halt the progression of this Alzheimer’s disease. And again, there is no other product until the recent ones that were approved. But this is something that is number one, inexpensive. You just need to take the right amount because you can get toxicity if you take too much Vitamin B6 for instance. The pyridoxine can produce lesions. Or if you take too little because for instance for Vitamin B12, sometimes you cannot absorb the vitamin from the food. This is associated with what is called pernicious anemia, that form of anemia that is linked to problems in the stomach that do not allow the Vitamin B12 to be transported to your organs. It also happens in the elderly, the lack of Vitamin B12 because with years that is decreasing the amount of acid and bacteria, tends to proliferate and to grow in the stomach. In some cases, we have to give B12 shots to the patient in order to sort of make sure that the appropriate levels of Vitamin B12 are present. But by the far, these group of vitamins, are the ones that have been shown to stop the progression of Alzheimer’s by the mechanism of lowering this Homocysteine that I was mentioning. But also, some of these vitamins can stop the expression of genes that produce Alzheimer’s disease in the same way that the oncologists use some antivitamins to block the progression of the cancer. You block the gene expression. It doesn’t matter if you inherited the gene but if you can keep it without not working, that essentially is what you can do with some of these vitamins in the B12.

TODD: So, would those B vitamins be something that someone still healthy, not having any symptoms, might benefit from?

DR. ROMAN: Yes, yes, of course. Yes, of course, especially as I mentioned after a certain age, after 60 or 70, where the capacity of your body to take from the food the Vitamin B12 and utilize that is decreasing so you may need to give it a hand and take an extra pill. Usually, a sublingual tablet, over a 1,000 micrograms of Vitamin B12. So, you put it under the tongue, and it’s absorbed very quickly. So, these vitamins certainly are indicated as sort of the beneficial vitamin supplements that you can take after a certain age.

 

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ZACH: Dr. Roman emphasizes the benefit B6, B9, and B12 may provide in preventing dementia, so we wondered if any other vitamins or supplements might have a protective function against age related mental decline. Here’s what he had to say. “Vitamin C. There is some evidence Vitamin C may be associated with a lower risk of cognitive decline.” Dr. Roman suggests taking no more than 1 gram a day. Vitamin E. A few studies have found that Vitamin E supplementation may be associated with decreased risk of cognitive decline. It has not demonstrated any effect on Alzheimer’s in studies. Vitamin D. One recent large study found Vitamin D supplementation was linked to a significantly lower incidents of dementia. Dr. Roman emphasizes exposure to Vitamin D through the sun. Melatonin. Melatonin is currently being studied for possible cognitive benefits, but no verdict is in yet. Dr. Roman prescribes it for many patients for better sleep quality which is associated with a lower risk of cognitive decline. Fish oil. There have been reports that fish oil, more in foods than supplements, may reduce the risk of developing dementia because of the possible blood flow benefits. However, there isn’t very strong evidence at this point. Ginkgo biloba, the herb from China was once a big hope for its supposed mental benefits, but in clinical trials Ginkgo biloba failed to prevent cognitive decline or dementia. Resveratrol. The powerful compound in the skin of grapes was all the rage 15 years ago, thought to provide all manner of benefits including cognitive ones. Though research continues, Dr. Roman says it appears more beneficial in mice than in humans.

 

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TODD: So, how about research to develop medication to prevent the buildup of some of these things that cause Alzheimer’s much like statins to prevent the buildup of arterial plaque. Is that going on much?

 

DR. ROMAN: That is becoming the target. After the beta-amyloid being the main target for the past 15 or 20 years, all the effort of the pharmaceutical industry was trying to control the deposits of beta-amyloid in the synapses in the brain. To the point that maybe 20, 23 years ago the first the vaccine against Alzheimer’s was developed. They took the beta-amyloid, they isolated that, and then produced the vaccine where your immune system will attack the beta-amyloid in the brain and that will be removed in the blood vessels. It worked like a charm. You get the vaccine, the amyloid disappeared completely from the brain, but the new reaction was so strong that the patients started having hemorrhages in the brain and many of these patients died in the initial trial so that was a no, no. It was stopped completely. So, unfortunately, we still are not there in terms of being able to prevent this element of Alzheimer’s disease.

TODD: But now, the effort is more towards Tau methods. Some research there.

DR. ROMAN: Yep, we are, we are conducting a trial using a product that you can find is approved by the Food and Drug administration is you can find it in your health food stores. It's called L-Serine.It’s an amino acid. It’s part of the sort of building blocks of the proteins that has been found in experimental animals of Alzheimer’s disease and [indiscernible] that it prevents the deposition of this Tau protein which is one that is really destroys the neurons. So, we hope that it’s gonna be positive. We’re doing again strictly controlled, placebo-controlled trial where the patients get these gummy bears that contain the L-Serine and the other group receives the placebo, and they have to a PET scan at the beginning. That is the best way to measure how much changes there in the brain from the beta-amyloid and from the Tau. And after six months, they repeat the PET scan, and they repeat the comprehensive neuropsychology testing. And we hope that it will give us the possibility of preventing the development of Alzheimer’s disease with something less traumatic than the products that are currently approved.

TODD: I read so much about the failure of drugs to treat Alzheimer’s. Is this an avenue preventing it? The -- Perhaps, researchers should have gone down before more?

DR. ROMAN: Oh, yes. We hope so. There is a book on Alzheimer’s disease describing how not to study a disease because somehow, we got stuck with the amyloid and that became the central topic. For many years, the NAHU would not get funded for trial on Alzheimer’s if amyloid was not mentioned, so the pharmaceutical industry has invested millions and millions of dollars in products to control the amyloid, but maybe we’re barking up the wrong tree. So, the Tau certainly is important in the sense that it correlates much better with the severity of the disease. Amyloid, you can have patients with severe Alzheimer’s without amyloid, but if you correlate the degree of shrinking of the brain, the degree of atrophy with the volume of Tau protein, the correlation is very good. So, early in the disease you have Tau that is deposited only under the temple in the hippocampus in the temporal region of the brain, and it progresses invading finally the frontal areas, the executive function areas, and as the volume, as the number of these Tau proteins increases, the degree of dementia also gets worse. The correlation is with the Tau which destroys the neurons rather than with the amyloid. So, maybe we’re hoping that this products against Tau would also open the door to better prevention and prognosis for Alzheimer’s disease.

TODD: Are you hopeful that we’ll have something?

DR. ROMAN: Very much so, yes. I’m the P.I. for this study on L-Serine. So far, patients are tolerating that quite well. They are very enthusiastic so. I don’t know which one is getting the active product or not, but that’s a big hope that these will give us a chance to control the problem.

TODD: Is there anything you wanna add, to leave listeners with about dementia and what they can do to better their odds?

DR. ROMAN: Yes, I think the message is that even though we don’t have a cure yet, if you check with your doctor for early symptoms of what we call mild cognitive impermanence, memory loss, difficulty with word finding, difficulty finding the right word for your computer, difficulty with balancing your checkbook, difficulty with cooking and learning the recipes. You have to tell your primary care physician that you’re concerned, especially if there is a family history of someone developing dementia. Either grandma, or brothers, older brothers and sisters, so, because the earlier you get attention the better your future will be.

TODD: Alright, very good. Appreciate you taking time to talk with us.

 

DR. ROMAN: Thank you very much for the invitation.

 

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ZACH: Hearing this from Dr. Roman, what are some key points that you’re gonna take home with you and try to apply in your quest to better understand and prevent dementia?

 

TODD: Well, the one I’ve already started applying is one that our listeners won't have just heard because he only mentioned it to us after the tape stopped rolling.

ZACH: That actually happens quite a bit. We start packing up and then --

TODD: Yes.

ZACH: Our expert’s like, “Oh hey, by the way, well.

TODD: Yeah.

ZACH: [Laughter] But we’re sharing it here with you.

TODD: Yes. So, what he mentioned was that one thing he is really big on, as a possible preventative for dementia is extra virgin olive oil and not just cooking with it as much as possible, but he even said like it could not hurt to take a table spoon every day. So, I have started doing that.

ZACH: You know, that is interesting timing because recently I’ve seen that coffee shops, certain coffee shops are offering drinks with olive oil in them, like as an additive, like you know, spoonful of sugar, some milk, maybe some olive oil. Now, olive oil is something I’ve never consumed outside of cooking materials, or you know, bread [Laughter]. You know, at an Italian restaurant or something like that. And consuming it just by itself is not something that would have occurred to me but, you know, doctor recommended.

TODD: Yeah, I’m trying it. My previous experience was the same as yours, but I have noticed long before talking with Dr. Roman how much it’s considered a healthy ingredient. It’s one of the key components of a Mediterranean diet and it’s just touted generally for health benefits.

ZACH: What time of day are you taking this spoonful of olive oil, Todd?

TODD: You know, he suggested, I don’t know if he meant it strictly, but he suggested maybe in the morning.

ZACH: And with you being a night owl as we’ve established on this podcast, Todd, that’s probably like in the afternoon sometime when you get up, right?

TODD: [Laughter] That’s cute, Zach, but no, I was, I’m up early enough [Laughter] that the afternoon is the afternoon for me.

ZACH: No, and all jokes aside about sleep though, we cover a wide variety of topics on this podcast, but there seems to be a lot of overlap between these health subjects such as sleep. You know, we’ve talked about sleep, and getting enough, and how sleep is not just this endless bank you can keep pulling from, and sleeping four hours a night or three hours a night, and that stuff adds up over time. And you think about the short-term consequences of like, “Oh, I’m gonna be tired and wiped out for the next couple of days but I’ll power on through.” You do that enough it can start leading to potentially the road to dementia.

TODD: Yeah, Dr. Roman talked about, just for instance, as you get older and you get up to go to the bathroom a lot during the night, how detrimental that is to your sleep and thus your mental health.

ZACH: Mm hm. And that is definitely something I have taken away from this ‘cause you know, I think I’m like, “Oh, I got time. I’m not worried about it. I can overcome -- Not that I do all nighters anymore. “But I do overcome this or overcome that.” But, no, long term, right, these things add up, so that’s something I’m gonna be very cognizant of moving forward.

TODD: One thing he said that interested me was the talk about brain puzzles, exercises.

ZACH: Hmm.

TODD: Did you do anything like that? Do you do like crossword puzzles, Wordle?

ZACH: I used to do crossword puzzles all the time like in college because, you know, we didn’t have smartphones then. Dating myself, right? But -- And you had the newspaper which I also wrote on, by the way. Just side note. But, you know, I’d get my physical copy of the newspaper in college, read my article, flip it over, and then do the crossword, and your friends do ‘em. It’s a fun thing.

TODD: Were you good at crossword puzzles?

ZACH: Was very good at crossword puzzles, Todd.

TODD: Do you do the New York Times crossword puzzle?

ZACH: Oh, you know, that’s a challenging one. That’s like the big leagues of crossword puzzles. So, do you do that every day to keep your mind sharp?

TODD: No, no, I’m terrible at crossword puzzles.

ZACH: Okay, okay. [Laughter] How was The Chronicles’ crossword puzzle? How’d that rank?

TODD: Well, it’s not as difficult as the Times’ one, but I’ve never really done them because when I have in the past, I was bad at them.

ZACH: Okay.

TODD: I did recently -- Do you know the little, the jumble strip? It’s like they give you jumbled letters, and you have to make the word out of it, and then there’s a few key letters.

ZACH: I have seen this. Yes.

TODD: So, I used to be not very good at those either, but I did that recently and did it much better, so maybe my, you know, verbal skills are improving or something.

ZACH: Interesting. See, I’ve always seen crossword puzzles as less of a mind game but like a trivia thing. Like, “Oh, I happen to know this or that so I can fill in these answers.” But like, when you look at like a Sudoku and other things like that, those are mental processes of finding patterns and things, right?

TODD: Yeah, yeah. That stuff’s probably better. I have not, have not done that.

ZACH: No, I don’t like Math at all, so that has no interest to me.

TODD: I think at some point I will try doing stuff like that, but I haven’t got there yet.

ZACH: Yeah, and it kind of, it helps both sides of the brain really doing these mind exercises, right, because there’s the logical side but there’s the creative side like, “Oh, this picture and this shape fits in with that,” and that’s what I like doing. It's a fulfilling thing to do, you know, physical puzzles as well, right, getting -- We spend so much time on screens, right? It's nice to have that tactile and just using all the senses, right?

TODD: Right, yes. Well, I just hope it doesn’t come too late for me. You know, last night I filled my, late last night, I filled my car up with gasoline, put my wallet on the top of my car, and proceeded to drive off with it --

ZACH: Oh my god. Last night?

TODD: Yes. So.

ZACH: Did you go back and find it?

TODD: I went back, and it was by then about 12:30 --

ZACH: Okay.

TODD: And the --

ZACH: The little night owl here. Go on.

TODD: Right.

ZACH: Yeah.

TODD: It was closed, and I looked all over, it wasn’t there. I went back at 7:00 a.m. this morning, the gas station was open, but no one had turned it in. I looked again, nowhere to be seen. Was quite depressed but then I was overjoyed a little later when a good Samaritan called and had found my wallet and I was able to retrieve it today.

ZACH: Wow. There is still good in this world.

TODD: Yes, yes. But it was a little sobering when I realized I had put my wallet at the top of the car and just driven off with it like that.

ZACH: Well, I think I wouldn’t raise a red flag just yet for you because I feel like we all have had those absentminded moments, right? I think that’s something to remember for the listeners too. Like, just because, “Oh no, I lost my keys one day,” it doesn’t mean you’re on the road to dementia so to speak. We all have those moments.

TODD: Right. Although, with losing your keys, they say if it becomes a frequent occurrence, you, it might be time to start worrying.

 [Laughter]

ZACH: Well, ultimately, you know, I think Dr. Roman, he gave us a lot of good insight into the various types of Dementia, what they look like, and then also what to look out for and as you said, perhaps prevent moving forward.

TODD: Yes, well, I’m hoping he’s right.

ZACH: Alright, well, that’s gonna do it for us this week on the On Health Podcast. And we encourage you all to go to our blog at houstonmethodist.org/blog, and to share, like, and subscribe to our podcast. New episodes drop Tuesday mornings, so until then, stay tuned and stay healthy.

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