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How to Prevent Cognitive Decline

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Peter Whitehouse on how to prevent dementia and the limits of pharmacotherapy for cognitive decline. And the word of the day: Ultradian cycling.

Chris Aiken, MD, Kellie Newsome, PMHNP, and Peter J. Whitehouse, MD, PhD, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

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Published On: 12/13/2021

Duration: 21 minutes, 12 seconds

Referenced Article:In the News: Aducanumab (Aduhelm),” The Carlat Psychiatry Report, November/December 2021

Transcript:

Today, Peter Whitehouse gives us an inside look at the brain – from amyloid plaques to neurofibrillary tangles – to see what causes dementia and what prevents it.

Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

KELLIE NEWSOME: We’re going to pick up where we left off on November 15th, where we learned about the new FDA approved medication for dementia – Aducanumab (Aduhelm). This medication is groundbreaking in at least one way – it’s the first neuropsychiatric med to gain approval on the basis of its mechanism of action. Aducanumab reduces amyloid plaques, which may be a cause of dementia, or may not, they may just be an associated finding. 

CHRIS AIKEN: But that’s not all it does. It also causes small brain bleeds and brain swelling, which can’t be very good for dementia. 1 in 5 people develop microhemorrhages in the brain on it, and 1 in 3 develop cerebral edema.

KELLIE NEWSOME: Aducanumab is not the cure we were hoping for, and it may not even treat dementia depending on whether you take an optimistic view of the data or look at it with the skeptical eye of statistical rigor. Last month Peter Whitehouse gave us a neurologist’s view of the drug, and today he’s going to talk to us about how we can advise our patients who are worried about cognitive decline and want to prevent dementia.

CHRIS AIKEN: Thank you for coming back Peter. I’ve finished your new book, American Dementia: Brain Health in an Unhealthy Society. You’re writing about dementia, but I saw a lot of parallels to what is going on with psychiatric illnesses as well – in the way that we’ve invested unrealistic hope in pharmacologic cures for mental illness while defunding many of the social supports that were in place – the kind of therapeutic programs our patients need when their antipsychotics or antidepressants are not working 100%. And part of this is that we don’t even know for sure what is causing these illnesses, but we have lots of leads. So what are the leading theories on what causes dementia?

[Dr. Whitehouse’s response]

CHRIS AIKEN: What are the main environmental risks in dementia?

[Dr. Whitehouse’s response]

CHRIS AIKEN:CHRIS AIKEN: What can people do to reduce their exposure to heavy metals in the water?

[Dr. Whitehouse’s response]

CHRIS AIKEN: Psychiatrists don’t treat dementia much, but we often see older adults who want medications for cognitive decline. Do the dementia meds help?

[Dr. Whitehouse’s response]

CHRIS AIKEN: What about brain fitness apps and programs?

[Dr. Whitehouse’s response]

CHRIS AIKEN: I looked at a review article of the brain apps and it seemed the ones with the best evidence were dexterity games – like wii sports. Can table tennis, darts, bowling, and other dexterity games improve cognition or prevent dementia?

[Dr. Whitehouse’s response]

CHRIS AIKEN: Sometimes I wonder if the key ingredient is not the activity – whether it’s painting, or equine therapy, or listening to music – it’s not the activity that matters but the enjoyment that it brings. And what’s enjoyable to one may not be to another. For example, nature is usually relaxing, but I saw a study where they looked at how sitting in a beautiful forest affected type A – the driven, compulsive, competitive types – vs. type B – which is the opposite, the more laid back, daydream believers. The type B’s became more relaxed when they sat in the forest, but for the type A’s it did nothing. 

[Dr. Whitehouse’s response] 

CHRIS AIKEN: So it’s a chicken and egg thing. We don’t know if people with a sense of purpose were born with more resilient brains to begin with, or if the sense of purpose itself is what prevented the dementia.

[Dr. Whitehouse’s response]

CHRIS AIKEN: Speaking of sense of purpose… Is depression a risk factor for dementia?

[Dr. Whitehouse’s response]

CHRIS AIKEN: A lot of my patients with depression have read about this and it frightens them. What can we tell them to do that will prevent dementia?

[Dr. Whitehouse’s response]

CHRIS AIKEN: In this month’s Carlat report we covered a new controlled trial suggesting that simply wearing a hearing aid can treat depression in people with hearing loss. Does that help cognition as well?

[Dr. Whitehouse’s response]

CHRIS AIKEN: OK so we’ve got exercise, socializing, having a sense of purpose in life, learning…. Are we missing anything here like a healthy diet, good sleep…

[Dr. Whitehouse’s response]

CHRIS AIKEN: Would you put anticholinergics high on that list to avoid?

[Dr. Whitehouse’s response]

CHRIS AIKEN: What about a Mediterranean style diet?

[Dr. Whitehouse’s response]

KELLIE NEWSOME: Peter Whitehouse is the author with Daniel George of American Dementia: Brain Health in an Unhealthy Society. He is a professor of neurology at Case Western Reserve University where he holds a secondary professorship in psychiatry.

And now for the word of the day…. Ultradian cycling

KELLIE NEWSOME: Still, it’s not easy to tell the difference between borderline and bipolar disorder, and next week we’ll interview an expert from the land down under, when Gordon Parker unveils the Sydney Mood Screener, the first rating scale that separates normal highs from true bipolar.

KELLIE NEWSOME: Follow the link in the podcast notes to earn CME points for this episode. All you have to do is answer a few questions online – like this one, 

 

According to Dr. Whitehouse, which of these lifestyle approaches has the best evidence to reduce the risk of dementia?

A. Brain fitness apps

B. Exercise

C. Mindfulness meditation

D. The Mediterranean diet

 

KELLIE NEWSOME: There are dozens of textbooks that tell you how to choose a psych med. But once you’ve chosen the right med, how do you prescribe it? Drs Aiken, Feder, and Carlat teamed up to bring you a new textbook, Prescribing Psychotropics: From Drug Interactions to Genetics. You’ll learn which skin patches are better tolerated than the oral form, whether to use Wellbutrin XL or Aplenzin, orally disintegrating lamictal or extended release, and of course Zopimist – the aerosolized Ambien. The book includes 70 charts and figures and special sections on fine-tuning your prescriptions to the patient’s age, gender, genetic testing, ethnicity, and drug and food interactions.

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