Dementia is a general term for a decrease in mental abilities due to illness or injury. Alzheimer’s disease is the most common form of dementia, accounting for 60-80% of all cases[1]. This type of dementia specifically refers to a progressive deterioration of the brain’s faculties, which leads to a decline in memory, language, and problem-solving abilities. The majority of people with Alzheimer’s disease are over 65 years of age. However, approximately 200,000 Canadians under the age of 65 are living with early-stage Alzheimer’s disease or another form of dementia1.

There is no single test that can diagnose Alzheimer’s disease. Instead, a diagnosis is made based on a combination of medical and cognitive tests, and an analysis of symptoms. There is no known cure for Alzheimer’s disease, but there are treatments that can help manage some of the symptoms. Alzheimer’s disease is Canada’s fifth leading cause of death and the only one of the top 10 that cannot be prevented, cured, or even slowed1.

However, it is interesting to note that this last statement is increasingly questioned since certain studies have proven that optimal management of lifestyle habits can promote the well-being of sufferers by improving their symptoms and slowing the progression of the disease, even reversing the disease at an early stage in some cases[2] [3] [4] [5] [6].

In the previous article, we discussed the different etiological subtypes of cognitive decline and in this article, we will discuss concrete actions that can be taken simultaneously to support cognitive health. Each intervention has been the subject of significant scientific analyzes having demonstrated their relevance in maintaining and improving neuroplasticity, that is to say, the development of new neuronal connections in response to stimuli of all kinds.

1. Diet

The basis of diet is based on several international studies and the work of Dr. Dale Bredesen who named this dietary approach “KetoFlex 12/3”. By dissecting the appellation, we can better understand what this approach represents. The portion “Keto” refers to the principle of ketosis which is a natural process that takes place when the body breaks down fat for energy and produces ketones which can provide fuel to the brain instead of sugar with all the metabolic consequences that it can bring. The “Flex” portion refers to metabolic flexibility, i.e., the ability of the metabolism of cells to easily vary between carbohydrates and lipids (fats) to manufacture energy and thus easily and quickly produce ketones as accessible fuel for the brain. The “Flex” portion also means that the diet is “flexible”, that is to say that the consumption of food comes from different sources (animal, vegetable) to increase the variety of nutrients ingested. The “12” refers to a minimum fasting period of 12 hours where the body takes a break from eating. This period extends from the evening until the next day (i.e., at the end of the day’s final meal, until lunch the next day). The “3” portion of KetoFlex 12/3 refers to a minimum period of 3 hours between the last meal of the day and bedtime. Dr. Bredesen’s team has also taken up more specific concepts by encouraging people to eat as little processed food as possible while incorporating qualitative notions such as reducing glycation end products which are linked to higher levels of inflammation[7].

2. Physical activity

Physical activity is one of the best scientifically referenced topics related to the prevention and reduction of symptoms of cognitive decline. Like each category of intervention, this one is more effective when it is combined with the other categories simultaneously. Whether it’s taking outdoor walks, weight training in a gym, aquafitness, or dancing with a partner, movement can take a variety of equally beneficial forms than the others. The goal is to find a formulation that generates pleasure, that allows both social exchanges and is adapted to our physical abilities. New research shows that even people at the highest genetic risk of developing Alzheimer’s disease can reduce their chances of developing the disease by combining exercise with other healthy lifestyle support strategies. Indeed, a recent study[8] revealed that people with the presence of amyloid beta proteins (proteins present in Alzheimer’s disease) are protected against the progression of cognitive decline by walking a minimum of 8,900 steps per day. As cognitive health is largely influenced by metabolic health, there are some very interesting effects related to physical activity. It may help maintain a healthy body mass index (BMI), reduce insulin resistance, decrease inflammation, improve blood pressure, and reduce the risk of heart disease and cerebral stroke. Physical activity also reduces stress and anxiety, while improving mood and sleep.

There are four main groups of physical activity: aerobic, anaerobic, flexibility & mobility, and balance & coordination[9]. Aerobic exercises are also called endurance or cardio exercises. Walking, swimming, and cycling are such exercises. Anaerobic exercises are also called strength and power exercises. We are referring here to muscle training at the gym or with similar devices at home. Exercises using elastic bands are also of this type. Aerobic exercise has been extensively studied in cognitive decline and works via various mechanisms[10]. This type of exercise increases blood flow and regulates the BDNF factor which is considered a fertilizer for the brain. In addition, this type of activity reduces the levels of tau protein, these protein tangles are characteristic of Alzheimer’s disease. In addition, we note that older people who have a good aerobic condition maintain a better volume of their brain, have a greater cortical thickness (this is associated with a greater number of neurons and better cognitive health), and have a better integrity of white matter of the brain which helps in neuronal transmission. Overall, it improves critical thinking and planning skills. Ultimately, aerobic exercise is also associated with better cleansing of toxins from the brain via glial cells. These cells act as garbage collectors of the brain. These cells form the glymphatic system[11], which is also highly active during sleep. Thus, quality sleep allows the brain to perform its functions of cleaning and purifying unwanted materials (including the proteins produced in Alzheimer’s disease).

Anaerobic exercise is also important for cognitive health[12]. This type of exercise has been found to improve the volume and cognitive function of the brain. This type of physical activity also helps maintain muscle mass which, in addition, prevents bone loss, thus reducing the risk of fracture or osteoporosis.

3. Stress management

When we are under stress, our body circulates more adrenaline and cortisol. “Excess cortisol damages cells in the memory center of the brain. It prevents glucose from entering brain cells properly. It blocks the function of neurotransmitters and causes brain cell damage. High cortisol levels also impact the ability to learn and retain new information (this is called short-term memory loss). The more stress and cortisol levels increase, the greater the risk of developing memory loss[13]. Stress not only contributes to causing and maintaining several pathologies but also exacerbates their symptoms. Stress also has the ability to trigger the existence of other comorbidities such as depression and anxiety, which are two mood disorders that often coexist with Alzheimer’s disease[14]. People with depression are twice as likely to develop Alzheimer’s disease[15]. The same risk exists with post-traumatic stress disorder when studied in veterans[16]. In animal models, we know that stress exacerbates the symptoms of Alzheimer’s disease[17]. There are thus close links between the regulation of emotions and its impact on the cognitive function of the brain.

4. Sleep optimization

Sleep is important for Alzheimer’s disease and cognitive decline in general. There is several bi-directional evidence between sleep disturbances and pathophysiological changes seen in pathology. It is now known that sleep duration and sleep quality in adulthood are associated with the risk of cognitive decline[18]. Sleep-related problems are also known to be associated with neuroinflammation, atherosclerosis, and impaired amyloid clearance likely due to dysregulation of the glymphatic system, the brain’s emptying system[19]. In both men and women, it is also known that lack of sleep is associated with a poor quality of life at the social, emotional, cognitive, and behavioral levels[20]. Sleep would even affect the deposition of amyloid plaques in the brain, a hallmark characteristic of Alzheimer’s disease[21]. Finally, in the more advanced stages of the disease, there is a lot of sleep disturbance affecting the quality of life of the person affected but also the quality of life of their loved ones[22]. The phenomenon of sundowning refers to a form of confusion associated with a disruption of the circadian rhythm. At this time, we find agitation, increased confusion, and sometimes hallucinations[23]. With a view to prevention, it is imperative to detect and treat sleep apnea syndrome appropriately and to maintain optimal sleep hygiene.

Sleep management for many people with Alzheimer’s is problematic long before the first signs of the disease. Many then turn to medication. This medication, certainly effective for sleep, nevertheless has serious consequences at the cognitive level. A scientific article from the British Medical Journal even shares a statistic that indicates that when people take benzodiazepines for 3 to 6 months, they increase their risk of suffering from Alzheimer’s disease by 32%[24]!

5. Cognitive stimulation

Cognitive stimulation is crucial for preserving cognitive reserve in the brain. Cognitive reserve is defined as the brain’s way of coping with brain damage by using pre-existing neural networks or by activating new connections[25]. The cognitive reserve would be dependent on the level of education and the level of cognitive stimulation during active life[26]. Continuous learning is a significant source of brain stimulation that has been extensively studied in cognitive decline[27]. In addition to learning, stimulating activities and social engagement are known to be important factors in protecting the brain[28]. Research doesn’t yet agree on which types of cognitive stimulation are most effective. Whether it’s playing cards, doing a crossword puzzle, calling the kids or grandkids, learning a new language, knitting or crafting, playing a game on an app, or playing a musical instrument, cognitive stimulation is central to preserving function.

6. The environment and cognitive health

Dr. Dale Bredesen created a neologism with the word “dementogenic”. It means an element coming from the environment that can contribute to triggering (not necessarily on its own) or exacerbating an already installed cognitive decline. There are many problematic environmental sources. For example, heavy metals such as aluminum, lead, mercury, and arsenic which may be present in contaminated water or food and/or via industrial occupational exposure, for example. Also, residues of mycotoxins from molds that have grown on damp and poorly maintained structures to which one may have been exposed to regularly. Finally, there are also organic chemicals like pesticides, paint thinners, and petroleum products that we are exposed to daily. Significant environmental exposure to pollutants can be completely inconsequential for some, but highly problematic after several years for individuals who carry certain genetic predispositions to detoxify these kinds of substances less naturally.

Our internal environment can also be problematic on some level. Indeed, our body is made up of various systems which are in communication with each other, including our intestinal microbiota (extending from the mouth to the colon). A growing body of research is linking the cognitive decline to a bacteria found in the mouth that causes gum inflammation and cavities called P. gingivalis[29]. In addition, the family of the Herpes virus also seems to have a link with the risk of developing Alzheimer’s disease. [30]

7. Targeted tools: bring meaning to the life of the person affected and their loved ones

The Montreal approach or the partnership between patients, their loved ones, and the various players within the healthcare system[31] is intended to be a therapeutic alliance aimed at the self-determination of the person in order to co-construct together care that makes sense for the person and their entourage as well as care and emphasis towards health education in order to stimulate the person’s commitment. In the early 2010s, we were talking about a patient-centered approach. Here, we are talking more about a real partnership between the patient and the health professionals. In the Montreal approach, we also integrate groups of people suffering from the same health problems in order to be able to exchange with them, to feel less alone in our reality, and to be able to learn from the reality of each other[32] .

In this sense, we are particularly interested in the Montessori approach. This method was created in the early 1900s by Maria Montessori, a German doctor who created from scratch a new way of educating children following a very diligent observation of a group of children entrusted to her. These children were experiencing developmental delays and Maria Montessori felt that the problem was more educational than medical. The Montessori method for cognitive decline and aging stems from the work of Dr. Cameron Camp[33]. The objective of the program is to restore an environment where the affected person can be autonomous in doing tasks that they like and that makes sense to them[34].It is an innovative approach providing a rich environment of clues and support, allowing them to accomplish what they desire by facilitating several variables. The approach is always based on the dignity and respect of everyone. A group of international experts has been created to oversee this new method and train workers to deploy this method in various care settings. We then speak of organized environments where interesting material is within the reach of the person affected and is based on their interests. Dr. Cameron Camp believes that we should work with the preserved abilities of the person and not on the diagnosis which leads to deficiencies[35].  The activities must also allow the person to have control over their life[36]. For example, if you have been a stay-at-home mom, you will be more inclined to do activities to restore your ability to set the table nicely to invite your children to dinner, than to paint by numbers with strangers in a room you’ve never been to. Whether choosing, folding or ironing clothes, doing household chores such as light repairs or maintenance, helping to prepare meals or gardening, the Montessori method will provide a helping, and not infantilizing, framework for the person to work with procedural memories (those memories deeply inscribed in us since we have repeated them all our lives).

In conclusion, it is crucial that affected people and their loved ones realize all the power they have over their health through the optimization of lifestyle habits in different spheres, simultaneously. It is clear that this awareness of the relevance of a healthier lifestyle has much more power than any drug tried in the hope of slowing the progression of the disease. In addition to helping cognitive health, the implementation of healthy lifestyle habits has the happy side effect of helping metabolic problems, the risk of cancer, being overweight, mood disorders, etc. And of course, it is never too late to act!

 

 

Anne-Isabelle Dionne, MD

Dr. Dionne has been a general practitioner since 2014 and practices in intensive care at the Honoré-Mercier Hospital in St-Hyacinthe as well as in an FMG on the South Shore of Montreal. In 2018, she founded a preventive medicine center specializing in supporting people suffering from various health problems in improving their daily lifestyle habits through diet, physical activity, stress management, and sleep. Le Centre Axis is an NPO that offers multidisciplinary preventive care to the general population wishing to improve their health and prevent or reverse a known chronic disease while reducing the need for associated medication. The services of Le Centre Axis can be dispensed remotely through telemedicine. To contact us: 514-953-2947 or info@centreaxis.ca.

Cynthia Gariepy, ND

Cynthia Gariépy has been a certified naturopath since 2003 and practices in private clinics as well as at the Le Centre Axis. She has been working in integrative health for over 20 years. She accompanied her mother for 14 years as a caregiver when she was diagnosed with Alzheimer’s disease.

The Montessori Alzheimer Center, located in the Portneuf region, is responsible for the dissemination and training of the Montessori Alzheimer method. You can contact Marc Norris, director of this organization at https://montessori-alzheimer.com

 

References:

[1] https://alzheimer.ca/fr/au-sujet-des-troubles-neurocognitifs/quest-ce-que-la-maladie-dalzheimer/la-difference-entre-la

[2] Rao RV, Kumar S, Gregory J, Coward C, Okada S, Lipa W, Kelly L, Bredesen DE. ReCODE: A Personalized, Targeted, Multi-Factorial Therapeutic Program for Reversal of Cognitive Decline. Biomedicines. 2021 Sep 29;9(10):1348. doi: 10.3390/biomedicines9101348. PMID: 34680464; PMCID: PMC8533598.

[3] Snowdon DA; Nun Study. Healthy aging and dementia: findings from the Nun Study. Ann Intern Med. 2003 Sep 2;139(5 Pt 2):450-4. doi: 10.7326/0003-4819-139-5_part_2-200309021-00014. PMID: 12965975.

[4] Kivipelto M, Mangialasche F, Ngandu T. Lifestyle interventions to prevent cognitive impairment, dementia and Alzheimer disease. Nat Rev Neurol. 2018 Nov;14(11):653-666. doi: 10.1038/s41582-018-0070-3. PMID: 30291317.

[5] Kivipelto M, Mangialasche F, Snyder HM, Allegri R, Andrieu S, Arai H, Baker L, Belleville S, Brodaty H, Brucki SM, Calandri I, Caramelli P, Chen C, Chertkow H, Chew E, Choi SH, Chowdhary N, Crivelli L, Torre R, Du Y, Dua T, Espeland M, Feldman HH, Hartmanis M, Hartmann T, Heffernan M, Henry CJ, Hong CH, Håkansson K, Iwatsubo T, Jeong JH, Jimenez-Maggiora G, Koo EH, Launer LJ, Lehtisalo J, Lopera F, Martínez-Lage P, Martins R, Middleton L, Molinuevo JL, Montero-Odasso M, Moon SY, Morales-Pérez K, Nitrini R, Nygaard HB, Park YK, Peltonen M, Qiu C, Quiroz YT, Raman R, Rao N, Ravindranath V, Rosenberg A, Sakurai T, Salinas RM, Scheltens P, Sevlever G, Soininen H, Sosa AL, Suemoto CK, Tainta-Cuezva M, Velilla L, Wang Y, Whitmer R, Xu X, Bain LJ, Solomon A, Ngandu T, Carrillo MC. World-Wide FINGERS Network: A global approach to risk reduction and prevention of dementia. Alzheimers Dement. 2020 Jul;16(7):1078-1094. doi: 10.1002/alz.12123. Epub 2020 Jul 5. PMID: 32627328.

[6] Livingston G, Huntley J, Sommerlad A, Ames D, Ballard C, Banerjee S, Brayne C, Burns A, Cohen-Mansfield J, Cooper C, Costafreda SG, Dias A, Fox N, Gitlin LN, Howard R, Kales HC, Kivimäki M, Larson EB, Ogunniyi A, Orgeta V, Ritchie K, Rockwood K, Sampson EL, Samus Q, Schneider LS, Selbæk G, Teri L, Mukadam N. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet. 2020 Aug 8;396(10248):413-446. doi: 10.1016/S0140-6736(20)30367-6. Epub 2020 Jul 30. PMID: 32738937; PMCID: PMC7392084.

[7] Abate G, Marziano M, Rungratanawanich W, Memo M, Uberti D. Nutrition and AGE-ing: Focusing on Alzheimer’s Disease. Oxid Med Cell Longev. 2017;2017:7039816. doi: 10.1155/2017/7039816. Epub 2017 Jan 12. PMID: 28168012; PMCID: PMC5266861.

[8] Rabin JS, Klein H, Kirn DR, et al. Associations of Physical Activity and β-Amyloid With Longitudinal Cognition and Neurodegeneration in Clinically Normal Older Adults. JAMA Neurol. 2019;76(10):1203–1210. doi:10.1001/jamaneurol.2019.1879

[9] https://apps.who.int/iris/bitstream/handle/10665/44399/9789241599979_eng.pdf?sequence=1&isAllowed=y accessed March 22, 2022

[10] Morris, J. K., Vidoni, E. D., Johnson, D. K., Van Sciver, A., Mahnken, J. D., Honea, R. A., Wilkins, H. M., Brooks, W. M., Billinger, S. A., Swerdlow, R. H., & Burns, J. M. (2017). Aerobic exercise for Alzheimer’s disease: A randomized controlled pilot trial. PloS one, 12(2), e0170547. https://doi.org/10.1371/journal.pone.0170547

[11]https://www.sciencepresse.qc.ca/blogue/cerveau-niveaux/2019/02/13/systeme-glymphatique-egouts-cerveau

[12] McGough, Ellen L. PT, PhD1; Lin, Shih-Yin MM-BC, MPH, PhD2; Belza, Basia RN, PhD2,3; Becofsky, Katie M. PhD4; Jones, Dina L. PT, PhD5; Liu, Minhui RN, PhD2,6; Wilcox, Sara PhD7; Logsdon, Rebecca G. PhD2,3 A Scoping Review of Physical Performance Outcome Measures Used in Exercise Interventions for Older Adults With Alzheimer Disease and Related Dementias, Journal of Geriatric Physical Therapy: January/March 2019 – Volume 42 – Issue 1 – p 28-47 doi: 10.1519/JPT.0000000000000159

[13] https://alzheimersprevention.org/4-pillars-of-prevention/pillar-2-stress-management/ accessed March 22, 2022

[14] Justice N. J. (2018). The relationship between stress and Alzheimer’s disease. Neurobiology of stress, 8, 127–133. https://doi.org/10.1016/j.ynstr.2018.04.002

[15] Barnes D.E., Yaffe K., Byers A.L., McCormick M., Schaefer C., Whitmer R.A. Midlife vs late-life depressive symptoms and risk of dementia: differential effects for Alzheimer disease and vascular dementia. Arch. Gen. Psychiatr. 2012;69:493–498.

[16] Qureshi S.U., Kimbrell T., Pyne J.M., Magruder K.M., Hudson T.J., Petersen N.J., Yu H.J., Schulz P.E., Kunik M.E. Greater prevalence and incidence of dementia in older veterans with posttraumatic stress disorder. J. Am. Geriatr. Soc. 2010;58:1627–1633.

[17] Zhang C., Kuo C.C., Moghadam S.H., Monte L., Rice K.C., Rissman R.A. Corticotropin-Releasing factor Receptor-1 antagonism reduces oxidative damage in an Alzheimer’s disease transgenic mouse model. J Alzheimers Dis. 2015;45:639–650.

[18] Choe, Y.M., Byun, M.S., Yi, D. et al. Sleep experiences during different lifetime periods and in vivo Alzheimer pathologies. Alz Res Therapy 11, 79 (2019). https://doi.org/10.1186/s13195-019-0536-6

[19] Sabia, S., Fayosse, A., Dumurgier, J. et al. Association of sleep duration in middle and old age with incidence of dementia. Nat Commun 12, 2289 (2021). https://doi.org/10.1038/s41467-021-22354-2

[20] Petrovsky, D. V., McPhillips, M. V., Li, J., Brody, A., Caffeé, L., & Hodgson, N. A. (2018). Sleep disruption and quality of life in persons with dementia: A state-of-the-art review. Geriatric nursing (New York, N.Y.), 39(6), 640–645. https://doi.org/10.1016/j.gerinurse.2018.04.014

[21] Ju, Y. E., McLeland, J. S., Toedebusch, C. D., Xiong, C., Fagan, A. M., Duntley, S. P., Morris, J. C., & Holtzman, D. M. (2013). Sleep quality and preclinical Alzheimer disease. JAMA neurology, 70(5), 587–593. https://doi.org/10.1001/jamaneurol.2013.2334

[22] Ju, YE., Lucey, B. & Holtzman, D. Sleep and Alzheimer disease pathology—a bidirectional relationship.Nat Rev Neurol 10, 115–119 (2014)

[23] https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/symptoms/sundowning accessed March 22, 2022

[24] Billioti de Gage S, Moride Y, Ducruet T, Kurth T, Verdoux H, Tournier M, Pariente A, Bégaud B. Benzodiazepine use and risk of Alzheimer’s disease: case-control study. BMJ. 2014 Sep 9;349:g5205. doi: 10.1136/bmj.g5205. PMID: 25208536; PMCID: PMC4159609.

[25] https://www.vaincrealzheimer.org/2019/03/06/reserve-cognitive/ accessed March 22, 2022

[26] 5. Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C. Potential for primary prevention of Alzheimer’s disease: an analysis of population-based data. Lancet Neurol. 2014;13(8):788–794.

[27] Valenzuela MJ, Sachdev P. Brain reserve and cognitive decline: a non-parametric systematic review. Psychol Med. 2006 Aug;36(8):1065-73. doi: 10.1017/S0033291706007744. Epub 2006 May 2. PMID: 16650343.

[28] https://www.alz.org/help-support/brain_health/stay_mentally_and_socially_active accessed March 22, 2022

[29] Costa, M.J.F., de Araújo, I.D.T., da Rocha Alves, L. et al. Relationship of Porphyromonas gingivalis and Alzheimer’s disease: a systematic review of pre-clinical studies. Clin Oral Invest 25, 797–806 (2021). https://doi.org/10.1007/s00784-020-03764-w

[30] Cairns DM, Rouleau N, Parker RN, Walsh KG, Gehrke L, Kaplan DL. A 3D human brain-like tissue model of herpes-induced Alzheimer’s disease. Sci Adv. 2020 May 6;6(19):eaay8828. doi: 10.1126/sciadv.aay8828. PMID: 32494701; PMCID: PMC7202879.

[31] https://publications.msss.gouv.qc.ca/msss/fichiers/2018/18-727-01W.pdf accessed May 18, 2022

[32] https://ceppp.ca/wp-content/uploads/2021/01/TERMINOLOGIE-de-la-pratique-collaborative-et-du-partenariat-patient-.pdf consulté le 18 mai 2022

[33] Camp C. J. (2010). Origins of Montessori Programming for Dementia. Non-pharmacological therapies in dementia, 1(2), 163–174.

[34] Camp CJ, Cohen-Mansfield J, Capezuti EA. Use of nonpharmacologic interventions among nursing home residents with dementia. Psychiatr Serv. 2002 Nov;53(11):1397-401. doi: 10.1176/appi.ps.53.11.1397. PMID: 12407266.

[35] Camp CJ. Denial of Human Rights: We Must Change the Paradigm of Dementia Care. Clin Gerontol. 2019 May-Jun;42(3):221-223. doi: 10.1080/07317115.2019.1591056. Epub 2019 Mar 20. PMID: 30892134.

[36] Mbakile-Mahlanza L, van der Ploeg ES, Busija L, Camp C, Walker H, O’Connor DW. A cluster-randomized crossover trial of Montessori activities delivered by family carers to nursing home residents with behavioral and psychological symptoms of dementia. Int Psychogeriatr. 2020 Mar;32(3):347-358. doi: 10.1017/S1041610219001819. PMID: 31762434.