Preventive Neurology

In summary, any form and any amount of alcohol consumption is unhealthy for the brain. Photo by Hush Naidoo on Unsplash He was only 64 when his daughter noticed that his forgetfulness had started to impact on his ability to function independently. Her father had forgotten to pay the gas and electricity bill and social services had contacted her as next of kin to find out why. It was clear that years of excessive alcohol was having an impact on his memory. The scenario above is one that is played out across society thousands of times if not hundreds of thousands of times. This is why the study below from the UK biobank is so worrying; when it comes to brain volume, a crude measure of the brain's neuronal and cognitive reserve, there is no safe alcohol consumption limit. Importantly, comorbidities such as high blood pressure and obesity interacted with alcohol consumption to reduce brain health. Not surprisingly binging on alcohol made things worse and this was over and above the vo...

I had a terrible night last night. One of my patients who has been under my care for over a decade was admitted to a district hospital with life-threatening sepsis and has to have emergency surgery. It is touch and go if this patient will survive. I kept tossing and turning and rehearsing events that led up to their admission and kept wondering if anything could have been done to prevent the sepsis from progressing to a stage when it required surgery. The result is I had a very poor night’s sleep and feel terrible this morning; irritable, tired, groggy and foggy as if I have a hangover. What damage has this caused? Photo by engin akyurt on Unsplash It is clear that sleep is a physiological must; acute sleep deprivation is a major life-threatening stressor and kills. This is why it is used as a method of torture. Chronic sleep deprivation is also a stressor and also kills, only more slowly. The paper by Eide and colleagues below shows how one night’s sleep deprivation impairs the brain...

Photo by Mark Paton on Unsplash We know that exercise is important for brain health has the potential to delay, or prevent, all cause-dementia in the general population. Hearing loss has recently also been identified as an important and potentially modifiable risk factor for dementia. Are hearing loss and physical activity related to each other? This study below shows in elderly people that hearing loss is associated with a worse physical activity profile. Is this association or causation? Is hearing loss part of the dementia prodrome and hence is associated with other prodromal features of dementia such as poor motivation, social isolation, lower mood, etc., which lead to less activity? Or is less activity in old age related to a lifetime of less activity and hence a higher risk of dementia and is simply associated with loss of hearing? Does hearing loss impact one's ability to exercise? Does less environmental auditory feedback make it less likely that you go out and exercise? I...

How soon is early enough? The study below supports the need for lifestyle behaviours to improve Brain Health having to start early even before you are middle-aged. In this study of 40- to 54-year-old employees of the Banco Santander in Madrid, Spain who didn’t have any apparent cardiovascular disease were assessed using the 30-year Framingham cardiovascular risk score (FCRS) and other investigations to detect atherosclerosis. A proportion of the 946 of the subjects who had early atherosclerosis underwent metabolic PET imaging of their brain to assess brain metabolism. Higher 30-year FCRS was associated with global and regional brain hypometabolism, particularly in the parietotemporal region. The carotid artery atherosclerosis burden was associated with this brain hypometabolism, which is an early biomarker of neurodegeneration. These people have poor brain health a reduced brain reserve and are at greater risk of dementia in the future. Importantly, it was hypertension that was the ma...

The costs of modifying the course of Alzheimer's disease with a biological therapy are mind-blowingly large. #BrainHealth #PreventiveNeurology The perspective in this week's NEJM is a sobering reminder of why we need effective preventive strategies for Alzheimer's disease (AD). If we have to rely on Pharma to deliver expensive biological disease-modifying therapies (DMTs) to treat the disease it may end up costing society an extortionist amount of money.  As most people with AD rely on the state for their healthcare can society afford expensive DMTs for symptomatic AD? I am not sure we can. People with symptomatic AD have already lost too much brain and slowing progression of their AD at this stage may be too late to have an impact on their, and their family's, QoL. The other issue is cost-effectiveness; most people with AD (pwAD) are aged and not economically active and hence any DMT will have to be relatively cheap to pass NICE's cost-effective threshold...

I predict a brave new world in which a significant proportion of the population will be receiving pharmacological interventions to optimise the ageing process. #BrainHealth #PreventiveNeurology The following study is a good example of the revolution that genomics has brought to the practice of medicine.  The discovery (2003) that gain-of-function mutations in the proprotein convertase subtilisin–kexin type 9 (PCSK9) gene causes autosomal dominant hypercholesterolaemia, and the identification (2005) of loss-of-function mutations in PCSK9 causing lower low-density lipoprotein (LDL) cholesterol levels, led to the PCSK9 pathway becoming a therapeutic target.  PCSK9 is a secreted serine protease that binds to the extracellular domain of the LDL receptor and targets the LDL receptor to the lysosomal compartment for degradation. PCSK9 prevents recycling of the LDL receptor to the cell surface, thereby attenuating LDL clearance. PCSK9 circulates in plasma, where it is closel...

Preserving the population's cognitive capital will reduce the burden of dementia on Society. #BrainHealth #HealthyAgeing At the 2017 Association of British Neurologists (ABN) meeting in Liverpool, Professor Martin Rossor, in his ABN Medalist Lecture, made the point that at a population level we should be attempting to preserve Cognitive Capital . He was making a plea for public health officials to focus on ways to encourage the population to preserve their cognition, which in turn would help delay the onset of neurodegenerative diseases. This is exactly our thinking and what underpins the hypothesis that to reduce all-cause dementia we should be testing population level prevention strategies targeting simple things such as vascular comorbidities and lifestyle factors that are established risk factors for dementia, or are associated with the development of dementia.   What are the chances of this strategy working for Alzheimer's disease (AD) the commonest cause of dementia...

Should we redefine ageing as a disease? #BrainHealth #ProfG #HealthyAgeing Most of neurologists equate amyloid deposition in the brain with Alzheimer's disease (AD). This study questions this assumption and suggests that amyloid deposition is simply a part of normal ageing. Demographics, the APOE genotype and midlife dyslipidaemia was associated with amyloid deposition. In comparison obesity, smoking, diabetes, hypertension, and cardiac and metabolic conditions, but not intellectual enrichment, were associated with greater AD-pattern neurodegeneration.  These results in elderly individuals supports the hypothesis that tackling common lifestyle factors obesity, smoking, diabetes, hypertension, and cardiac and metabolic conditions could prevent, or at least, delay the onset of symptomatic AD and is consistent with the falling incidence of AD in both the Cambridge and Framingham cohort studies.  Please note that although the incidence (number of new cases per 100,000 pe...

If you take #BrainHealth seriously you need to focus on diet. Do you buy into 'you are what you eat' ? This ambitious systematic  literature  review has identified 10 foods and 7 nutrients with evidence for causal cardio-metabolic effects. Any intervention that reduces your vascular risk burden should reduce all-cause dementia and improve your Brain Health.  The foods that were found to have  protective effects : fruits vegetables beans/legumes nuts/seeds whole grains fish yogurt fibre seafood omega-3s polyunsaturated fats potassium The food found to have  harmful effects:  unprocessed red meats processed meats sugar-sweetened beverages glycemic load (sugar or carbohydrates) trans-fats sodium/salt.  There is nothing new here and most of this should be obvious to you and is currently included in mots dietary guidelines. The elephant in the room is economics; in modern economies people eat what they can afford. Modifying ...

Information rarely changes health outcomes on its own, which is why we need policy #PreventiveNeurology #BrainHealth Although we have known about the cardiovascular risks associated with the consumption of trans fatty acids (TFAs) for decades little has been done by individuals to reduce their consumption. Therefore when the state of New York put in place restrictions on their use in 11 counties between 2007 and 2011 they set-up an experiment. This experiment now reports out: the study below included 25 counties and compared cardiovascular outcomes in the TFA non-restricted populations of 14 counties with the populations in the 11 TFA restricted counties. Three or more years after restrictions were put in place the people living in the counties with TFA restrictions experienced a significant decline in combined myocardial infarction and stroke events (-6.2%) compared with the TFA non-restricted populations.  I sincerely hope you appreciate the significance of these findings?...