September/October 2010

THE NEXUS INTERVIEW

BRAIN GAIN
Dr. Daniel Amen MD on brain health and Alzheimer's prevention

BY RAVI DYKEMA

In 1906, German physician Alois Alzheimer presented to his colleagues the case of a 51-year- old woman with memory loss, language problems, and behavior problems. Her autopsy showed brain abnormalities that were thought to explain her mysterious symptoms. Since then, the number of Alzheimer’s cases has grown yearly; estimates suggest that more than 5 million people may have the disease. And in spite of decades of research, no definitive treatments or preventive measures have been found for the devastating, and often fatal, disease.

What if that’s changing, if we could detect and prevent Alzheimer’s? Daniel Amen, psychiatrist, brain imaging specialist, best-selling author of 23 books, and CEO and medical director of The Amen Clinics, claims it’s possible. In Amen’s view, a type of functional brain imaging known as SPECT (single photon emission computed tomography) that measures the flow of blood in certain areas of the brain can identify Alzheimer’s. If detected early enough, he says, it can be slowed or even prevented.

His opinion isn’t shared by the majority of the medical community. Often-outspoken critics claim that SPECT scans aren’t sensitive or specific enough to diagnose Alzheimer’s, and that Amen’s views are less than scientific. Amen counters that the scans he performs at his clinic have a high degree of reliability, and that aggressive intervention can prevent the disease. Here, he talks to Nexus about the role of obesity in Alzheimer’s, the importance of protecting kids’ brains, and changes you can make right now to reduce your risk of the disease.

RD: Alzheimer’s is a big concern for our readers – not only in terms of caring for aging parents, but also in terms of preventing it in themselves.What can you tell us about preventing and treating Alzheimer’s?

DA: I’m a psychiatrist and I also do brain imaging, so I look at people’s brains day in and day out. And it’s very clear to me that the habits you have are either accelerating or decelerating the aging process. I conclude, if you want to prevent Alzheimer’s disease, you have to prevent the risk factors for it.

One of the biggest is brain injury. I’m in the middle of the world’s largest brain imaging/brain rehabilitation study of active and retired NFL players. We’ve scanned the brains of 101 players, since chronic traumatic brain injury is a risk factor for dementia.

RD: That includes everything from mild concussions on up?

DA: Yes – although when you’re talking about NFL players, “mild” is a widely subjective term. The NFL has a Committee on Mild Traumatic Brain Injury. But you stand next to Ron Yary, who’s 6’6” and 300 pounds, and then tell me having him hit you 30 times a game is “mild” traumatic brain injury. The words we use are just dumb.

I think slipping and falling on the floor, where you don’t hit your head but your brain gets rattled, probably won’t have any long-term effect. If you’re in a car accident where you get rear-ended by someone going 70 mph, that’s likely to have a more lasting impact. In any case, if you have brain injury, you need to have it treated, and do whatever you can to reverse it.

RD: What’s another risk factor?

DA: Brain reserve is another consideration in preventing Alzheimer’s. How much extra brain tissue do you have to deal with the chronic stresses that come your way, including getting in a car accident or having another kind of brain injury? If you have a lot of reserve, you’re less likely to end up with dementia than if you have no reserve.

RD: Is there anything we can do to boost our reserves?

DA: Definitely. Every day, through your habits, you’re either boosting or stealing from your reserve. So if you don’t sleep, you’re depleting your reserve: decreased sleep – less than 6 hours per night – is associated with lower overall blood flow to your brain. Eliminating things that are toxic for you: nicotine, too much caffeine, too much alcohol, certain medications that suppress blood flow to the brain, like pain killers and benzodiazapenes, anti-anxiety medications, steal your reserve.

Decreased vitamin D can increase your risk for Alzheimer’s disease, and two-thirds of people have low levels of vitamin D. It’s unbelievable. During one study at the Amen Clinic, we checked the vitamin D levels of the first 50 participants; all of them but two had low levels. And I live in Southern California. How is that possible? Because nobody’s outside taking a walk. Or if they are, they’re so afraid of the sun that they’re wearing sunscreen.

RD: Yes, or they’re covered up.

DA: That’s right. But vitamin D is a critical nutrient, and we evolved as a species in the sun.

RD: Yes, but we’re heard lots about the dangers of sun exposure producing cancer. So perhaps there’s just the right amount.

DA: Yes. And that “right amount” of sun—whether it’s too much or too little – also depends on the color of your skin. I read an article last week about people from the Bahamas who immigrated to the United Kingdom, and then showed a very high incidence of schizophrenia. Was it because of a sudden vitamin D deficiency? These people went from an area that sees sun 330 days per year to an area that has sun about 100 days per year. And when you have dark skin, it takes five times the sun exposure to get the same level of vitamin D.

But for the purposes of preventing Alzheimer’s disease, the consideration is to prevent nutrient deficiencies. Besides vitamin D, low levels of omega 3 fatty acids are associated with cognitive problems. So if you’re not getting enough omega-3 fatty acids, your brain reserve is going to be vulnerable.

RD: Are genetics a risk factor?

DA: If you have Alzheimer’s disease in your family, you need to be serious about prevention, because that’s a risk factor you can’t change. I worked with Leeza Gibbons, the television personality. Both her mom and her grandmother had Alzheimer’s disease. She and I have been talking for a long time and she knows she has a higher risk and that she needs to be on a prevention program. Her children already know about their possibly increased risk, and they’re on a prevention program which means they’re not going to play tackle football, they’ll take fish oil, and they’ll be careful about depression, because that’s another risk factor.

RD: You briefly mentioned alcohol earlier.

DA: Yes, as much as we like to think of alcohol as a health food, it adds many more problems than it does health benefits.

RD: Even the therapeutic dose of one glass of wine a night, four to five nights a week?

DA: Right. According to the imaging we have, the more you drink, the less blood flow you have to your brain. There’s also a study from John’s Hopkins that said people who drink every day have a smaller brain. That has been my experience. Now if you have four glasses a week, well maybe it’s helpful, because it helps to balance your triglyceride levels. But I would be very cautious with it; it’s hard to drink just one glass a night, and most people end up drinking two—or more. Alcohol suppresses your frontal lobes, so the more you drink, the worse your judgment, and the worse your memory.

So people may tell me “Oh, I just have one glass of wine a night,” but when you start to ask questions and look deeper into it, you’ll often find that’s not really the case. I’m not a complete teetotaler, but I think we should be much more careful with alcohol.

RD: What about other risk factors?

DA: Cardiovascular disease. Even though the brain is only 2 percent of your body’s weight, it gets 20 to 25 percent of the blood flow in your body, so it’s critical to prevent heart disease. If you already have it, it’s critical to be aggressive in treating it. If you have high blood pressure or atherosclerosis, if you have a heart arrhythmia, if you’ve had a heart attack, it’s critical to take it seriously. There’s also a high incidence of depression in people who have heart disease; there’s a huge connection between heart health and brain health.

RD: So diminished blood flow itself is, you think, a factor in developing Alzheimer’s.

DA: Yes. One of the diseases involved with decreased blood flow is sleep apnea, which is also a risk factor. Sleep apnea lowers overall blood flow to your brain, and it doubles the risk for Alzheimer’s, according to some studies.

One of the major causes of sleep apnea is obesity, which has now been associated with Alzheimer’s. Seven or eight studies have made this connection now. In one of those, researchers found that people who are overweight had 4 percent less volume in their brain, and their brains looked eight years older than the brains of people who were normal weight. Obese people who had a BMI (body mass index, a measure of body fat based on height and weight) more than 30 had 8 percent less volume, and their brains looked 16 years older than healthy people.

The question was, why is smaller brain volume linked with being overweight? Two reasons come immediately to my mind. One, fat stores toxic materials, so the more fat on your body, the more toxins you’re going to store in your body.

The second is, fat is not an inert mass; it’s an endocrine organ that produces all sorts of chemicals and hormones. Some of those are called cytokines, which are pro-inflammatory in the brain and in the body in general. As the fat on your body goes up, your inflammatory markers also go up. That can lead to inflamed blood vessels, which we now think is one of the causes of heart disease, and probably brain disease as well. So, to keep your brain healthy, you’ll want to do all the things that also prevent strokes and diabetes: lower your blood pressure, exercise, eat right, don’t smoke, and manage your stress.

RD: What about smoking?

DA: Definitely a risk factor. Initially, it was thought that smoking was not a risk factor and that, in fact, it appeared that smokers didn’t get Alzheimer’s disease. Then researchers figured out that Alzheimer’s is typically a disease of old people, and smokers died earlier than other people. When they corrected for the dead people, they found it was, in fact, a risk factor.

Untreated depression is also a risk factor. It’s usually associated with lower overall blood flow to the brain; if you get low blood flow from a head injury or from toxic exposure, you’re more likely to be depressed, and the longer your brain is starved of oxygen, the more likely you are to have cognitive problems.

In fact, depression is one of the differential diagnoses for Alzheimer’s disease. If somebody comes into my office and says, “I can’t remember anything, it’s getting worse,” I need to be asking myself “Do they have Alzheimer’s, or are they really depressed?” Sometimes treating depression can help them get their memory back. Dropping out of school early or being in a job that does not require lifelong learning is another risk factor. So keeping your brain young and agile by learning new things is critical to keeping it healthy.

RD: I’ve read much about this recently. Research does suggest that learning to play a musical instrument or changing professions into old age helps.

DA: I don’t know about music specifically, but people who keep their minds engaged have less incidence of Alzheimer’s disease. And the more educated you are, the more protective it is - so stay in school. But then you have to wonder if people who drop out of school do so because they have early brain dysfunction that then becomes magnified as they go on. Maybe dropouts had moms who smoked or had toxic exposure when they were pregnant, or maybe one of the reasons people don’t finish school or go far in school was because of a brain injury or some early traumatic event that then increases the risk for Alzheimer’s disease.

RD: Why would exercising your brain prevent Alzheimer’s?

DA: Doing crossword puzzles is like going to the gym to do biceps curls. But you have to do multiple things to work out your brain, as you do to work out your body. Just doing one set of exercises is silly. So doing crossword puzzles likely helps you work out the language part of your brain, the left front part of your brain. If you can find a regular physical exercise that engages the brain as well as the body, you’ll be reducing your risk factors for many of the diseases that are associated with Alzheimer’s, like heart disease and obesity.

RD: What kind of physical exercise?

DA: Dancing is wonderful. It works out your cerebellum and your parietal lobes, the top back part of your brain, which we know is involved early in Alzheimer’s disease. The parietal lobes are involved in your sense of direction, which you’ll need if you’re dancing with a partner. If you have to learn dance steps, you’ll be working out the temporal lobes, which are involved in naming things and memory.
Dancing also exercises your cerebellum, the back bottom part of the brain that’s involved in coordination and also thought coordination. You’ll also need a certain amount of rhythm, which will work out the temporal lobes. And if you’re dancing with a partner, you have to have reasonable judgment – that’s your frontal lobe. So dancing is a wonderful exercise that doesn’t just work out your heart, but also your brain.

RD: We’ve been talking about how to prevent Alzheimer’s. But once you have it, is there any treatment?

DA: When I see early Alzheimer’s disease or early dementia from whatever cause, I think of it as an emergency; if you have your first symptoms, that’s not early in the disease. That is, in fact, late in the disease. At that point, it’s important to be as aggressive as possible, to try to get those brain cells working again. I differ with many of my colleagues who say, “Why would you want to do anything? There’s nothing you can do, or there’s not good evidence that if you do something, it will make a difference.” In my experience, you can slow down the progression of Alzheimer’s with aggressive intervention.

I recently had a case as part of our NFL study. Ray White, who was a linebacker for the San Diego Chargers, recently brought his wife to see us. She had been diagnosed with frontotemporal dementia, which is a bad kind of dementia. When I scanned her brain, she had very low activity in her frontal lobe. It was disastrous. I told him, “I don’t know if we have anything that can help her, but if she was my wife, I’d do 40 sessions of hyperbaric oxygen treatments, I would put her on the same supplements I used to enhance brain function in my NFL group, and I would do neurofeedback, which is basically a brain workout program.

Ten weeks later, they came back and they were very happy. She was starting to groom herself again, her memory was better, she felt sharper, and on her scan we saw fairly dramatic improvement. It doesn’t always happen like that, but it’s just so exciting to think that if you can change somebody’s brain with targeted intervention, you can change his or her life.

RD: Some people in their 50s get what we jokingly call “half-zeimer’s,” where we forget a few more things than we used to. How would you characterize that situation?

DA: Because of bad brain habits and changing hormonal situations, many people in their 50s are getting lower blood flow to their brains, and they’re symptomatic. I have been able to show with a lot of our own patients that you can reverse that trend. First, I do a good work-up and make sure their vitamin D and omega-3 levels are good, and that their hormone levels are good.

RD: How do you test that?

DA: It’s a simple blood test or saliva test. Getting a hormonal imbalance corrected can make a huge positive difference not only in your level of energy and libido, but also your mood and your memory. In one fascinating brain imaging study at UCLA researchers put one group of menopausal women on estrogen versus a control group. There’s an area in the brain that has sort of a funny name, it’s called the posterior cingulate gyrus. It’s the first area that dies in Alzheimer’s disease, that we see on imaging. In the control group, that area continued to get less and less active over a 3-year period. In the estrogen replacement group, it continued to maintain its current level.

RD: Why do you think that happens? What is the connection between estrogen and this part of the brain?

DA: As estrogen levels decline in general, the blood flow to your brain declines. That’s why many women who go through menopause feel fatter and dumber and just cognitively less sharp.

RD: And the same for testosterone for men?

DA: The same for testosterone for men – or for women. So if your wife’s libido is terrible, it may not only be bad for your marriage, it could be bad for her brain.

RD: In terms of prevention, what would you recommend for young people, especially those who have a family history of Alzheimer’s? Is the typical teenage/early 20s lifestyle just disaster waiting to happen in terms of Alzheimer’s?

DA: It is, but it’s also a disaster for the rest of their life. I have a high school course in 42 states and seven countries where we teach kids how to take care of their brains. They love it, because they see it as a way to learn how to get into the college they want, or how to be more successful at maintaining a relationship. The typical teenager eats terribly, doesn’t sleep very well, often drinks, and engages in high-risk activities that have a greater likelihood of causing brain injuries. And your brain is not finished developing until you’re about 25 years old, so by not taking care of it early, you are delaying, or perhaps even permanently impairing, your development. I think to really get serious about preventing Alzheimer’s disease, we need to start teaching kids about their brains.

RD: You didn’t mention marijuana smoking as a risk factor.

DA: Funny you mention that, because I treat a fairly famous Hollywood producer who has smoked pot for 50 years and now has no memory. Off the top of my head, I don’t know about the research with marijuana smoking and the risk factor for Alzheimer’s disease. I’m betting it’s not helpful.

RD: How would you suggest public health officials change their strategies? I know Alzheimer’s is but one of many illnesses that plague us, yet it’s a significant one, and there’s a fair amount of worry about it. Do you have any advice for public health officials?

DA: I have all sorts of advice. The first one would be you should ban ultimate fighting. What’s the matter with them that they let that be legal? It’s going to dramatically increase the incidence of dementia pugilistica, which we’ve known about in boxers for about 80 years. It’s unbelievable to me that that’s legal.

RD: What about high school football?

DA: I think it’s a really dumb idea. So is letting children hit soccer balls with their heads. We have no love, honor or respect for the brain, and I think that needs to stop. It’s crazy that we have state-sponsored activities that are clearly damaging to brain function. Virginia Tech did a study where they put crash dummy sensors in the helmets of high school football players, and found that kids who played from the start of the game got hit in the head 30 to 50 times a game. How is that smart for a developing brain?

The other thing I would tell health officials is we have to clean up our diets. How we feed people in this country is just scandalous. The rate of overweight children has gone from 4 percent in 1982 to 35 percent in 2010. It’s a nightmare, and it has to be a nightmare for brain function. Diabetes in children has gone up, and depression has gone up.

We also need to let kids sleep. These 7 a.m. classes are crazy, because when you don’t sleep, your brain doesn’t work right.

RD: Any other suggestions for what we could do as a country?

DA: We could create depression-prevention programs in schools. We can teach kids how to correct the automatic negative thoughts that go through the brain. We know cognitive behavioral therapy or correcting negative thoughts has been found to be as effective as anti-depressant medication for depression. Why the heck wouldn’t we make a class for 3rd graders, 6th graders, and 9th graders in internal logic so they don’t have to get anxious or depressed?

Learning that you don’t have to believe every stupid thought you have is more important than learning quadratic equations. Not that I’m opposed to quadratic equations.

RD: That covers developing brains. What about older brains?

DA: I believe when people turn 50, they should get their brain scanned. When I turned 50, my doctor wanted me to have a colonoscopy. I asked him why he didn’t want to look at my brain. Isn’t the other end of my body just as important?

The incidence of Alzheimer’s disease is expected to triple in the next 40 years. If we have high risk factors, I think we should get scanned even earlier so we can get serious about prevention programming. I tell my patients “You do not want to have the dinosaur syndrome: big body, small brain, get extinct early.”