Dr. Mitchell Clionsky explains why dementia can be preventable

Editor’s note: We realize this is a rather-lengthy story, but it is chock full of good and important information. Forward From 50 recently added a new feature which allows visitors to listen to the content instead of reading it. To do so, simply highlight the entire story and click on the blue megaphone that appears above the highlighted section. Or you can listen to Dr. Clionsky in his own words by listening to his podcast interview.

Dr. Mitchell Clionsky is a neuropsychologist who has taken a keen interest in the brain health of people of all ages, but especially seasoned citizens.

He evaluates a patient’s ability to plan and engage in problem-solving by comparing what someone is supposed to be able to do at that age with the patient’s education and occupational background.

“For 45 years, I have been seeing people with cognitive decline from dementia or mild cognitive impairment,” he explained. “For 35 of those years, I have completed about 30,000 evaluations of people over 60 from many different backgrounds.

“I really like the ability to impact people’s lives. For me, there is always some new questions every day, which is what makes my job so interesting,” he added. “Because of the brain and how it works, I find this even more fascinating that I did when I was younger because we know so much more, thanks to having better tools.”

Dr. Clionsky co-wrote the book “Dementia Prevention: Using Your Head to Save Your Brain,” with his wife, Emily, who is a medical doctor.

Dementia is preventable

Data shows that 80 percent of people over 50 years of age are somewhat or very concerned about losing their cognitive ability.

“The good news is that, with proper approaches, we can reduce the likelihood of dementia by about 50%,” said Dr. Clionsky. “Many people are amazed by that statistic. It is based on well-developed research conducted by two primary groups, starting with The Lancet Commission, which was located primarily in Great Britain.

“Back in 2017, the commission published results of its first large-scale analysis of data which identified nine different factors that could reduce dementia by about 40 percent,” he added. “Three years later, the group published an update and came up with three other areas they thought were important, which further increased their probability.

“A few years after that, the same 12 factors were evaluated by the U.S. Health and Retirement Survey. That research showed 60% of dementia cases could be avoided,” said Dr. Clionsky. “So, you have two well-established measures suggesting between 40% and 60% of dementia cases – about one out of every two cases – are preventable. The question becomes, how do you reduce your risk to end up in the good area?”

Research shows by the time the average person turns 70, he or she has lost 40% of their brain function naturally. That includes processing speed, attention and memory.

“But it’s not true for everybody. Some people have lost a lot more by that point,” said Dr. Clionsky. “There are others who we call ‘SuperAgers.’ They think like they are in their 50s when they are really in their 80s. It’s not just raw processing speed or the number of details we can remember, but actually how our wisdom and understanding guides us in making decisions.”

Preserving cognition

The goal for older people switches away from simply remembering facts to preserving their cognition. That requires ensuring good health in general, specifically cardiovascular health, habits and lifestyle to positively impact their mental speed, information access, ability to learn and remember new information, as well as their ability to solve problems.

There are as many as six major types of dementia that impact older people; however, many people attribute the problem almost exclusively to Alzheimer’s disease.

“Dementia is a broad category, under which there are a number of ‘brands.’ Think of it like a car. You could have an Audi, a Saab, Porche or Chevrolet,” said Dr. Clionsky. “We typically confuse Alzheimer’s disease as being all dementias rather that one specific brand or type of dementia.

“Vascular dementia is probably as common, either by itself or in combination with Alzheimer’s,” he explained. “Vascular dementia is not just caused by strokes or transient ischemic attack, but also by changes in blood vessels that go into the brain. That influences the ability to carry oxygen and nutrients to all the different endpoints, like leaves on branches of a tree.

“Hypertension and smoking can cause changes in our blood vessels and their ability to circulate blood,” he added. “Diabetes is another major cause of changes to our circulation and the nerves around blood vessels, which can have a significant impact on how the brain works.

“Sleep apnea, and the ability to breathe well enough while we’re sleeping, deprives our brain of oxygen and causes damage to the endpoints of our vascular system. That’s a big one,” said Dr. Clionsky. “Frontotemporal dementia, which is what Bruce Willis has, is a very important type of dementia because its onset is usually detected when someone is in his or her 50s. However, the symptoms for Alzheimer’s and vascular dementia are more noticed in someone’s 60s, 70s and 80s.”

Types of dementia

Three other types of dementia can impact people over 50, such as:

  • Parkinson’s disease, which is not just a movement disorder, but can also affect thinking.
  • Chronic traumatic encephalopathy, which is caused by repetitive blows to the head through sports and other kinds of concussive events.
  • Drinking too much. Alcohol can cause real damage to the brain when consumed in excess, either through binge drinking or frequent drinking at higher-than-healthy levels.

“Even nonprescription medications we take can have an impact on our cognitive abilities,” said Dr. Clionsky. “People who have trouble sleeping, or who deal with allergies or a cold, may go to their pharmacy to get an over-the-counter medication, such as Tylenol PM or Advil PM, to ease symptoms or help them sleep. These contain diphenhydramine, otherwise known as Benadryl. They dry us out or make us sleepy, which is their intended purpose.

“But these same medications can add up, especially when combined with some prescribed medicines, to create an anticholinergic burden, which reduces the level of acetylcholine in your brain,” he added. “This drop in acetylcholine slows down our thinking ability, causes us to feel spacey and gets in the way of being able to think now.”

Heart medicine or things taken to control depression, tighten bladder output or to treat cold and sinus problems can play a role. Dr. Clionsky recommends people look for an anticholinergic burden calculator online, such as one found at www.acbcalc.com. By entering all the prescription and over-the-counter medications they take, it calculates a score.

“You can see whether or not you’re taking too many things that have an anticholinergic burden,” he explained. “The really cool thing is you can decide if you really need to take that over-the-counter medication. Or you can talk to your doctor and express your concern to see if an alternative can be found.”

Terrible sleep habits

People in general, and Americans in particular, have developed terrible habits regarding their sleep, said Dr. Clionsky.

“When we can’t sleep, we often try harder and that just gets in the way. You don’t ‘get yourself to sleep,’ rather you surrender to sleep,” he explained. “People with sleep problems don’t always go to bed to sleep. Instead, they set up shop in their beds. They watch TV, scroll through social media, talk on their phones, or look through their phones while eating a snack.

“That confuses the brain, which wonders what it’s supposed to be doing. Are we going to sleep or just hanging out?” he added. “Your brain may really want to go to sleep right now, but it doesn’t have a signal that it’s time to go to sleep.

“So, when people are having trouble sleeping, we tell them they must change their habits around sleep,” said Dr. Clionsky. “They must stop using their beds as a place to live. If you’re tired, I want to you to go to sleep a little later rather than earlier. “You are often worried you won’t fall asleep, and that’s part of what’s getting in the way.”

“You may also be having trouble falling asleep, not sleeping well or sleeping enough because you’ve stopped exercising. You sit around all day, then try to force yourself to go to bed even though you are not tired. And then you start doing things that keep you awake,” he added. “It’s not surprising you’re having trouble sleeping. Changing your sleep behaviors rather than sedating yourself with a medication will often achieve a better result.”

Sleep apnea

Many people snore when they sleep. The older they get, the louder they sound. Snoring signals a problem with an obstructed airway in that air can’t get through the windpipe. It’s an annoying problem for some people, but can be deadly for others.

People with sleep apnea actually stop breathing in their sleep. It is measured by the number of times a person stops breathing every hour while asleep, and the number of times their oxygen level drops by 4% or more, Dr. Clionsky explained. 

“When you stop breathing, it is called an apnea. However, when you’re still breathing, but your oxygen level falls, it is called a hypopnea,” he added. “During a sleep study, the number of apneas and hypopneas are added together and divided by the number of hours the person has been sleeping. That number is called the AHI or apnea hypopnea index.

“If the number is five or more, that means your breathing gets dysregulated five times or more per hour, and that very likely means you’ve got obstructive sleep apnea,” he noted.

When sleeping, the brain detects the lack of oxygen and tries to jar the person awake. Sleep apnea can leave people feeling tired, even after a night of sleep. That’s because their brains are waking them up multiple times during the night.

“A recent study looked at 6,000 people ages 58 and older at seven different research centers. It revealed 50% of study participants had sleep apnea and did not know it,” said Dr. Clionsky. “By the time a person gets into his or her 70s, that number is probably closer to 70%. In patients I see who have cognitive problems, that number is even higher.”

To combat the problem, doctors often prescribe sleeps studies to detect those type of conditions, and then prescribe devices, such as continuous positive airway pressure (CPAP), to help patients maintain their breathing throughout the night. The person with sleep apnea wears a mask connected to a small machine that puts room air under pressure and forces it through a hose into their mask. That opens up their airway and lets them breathe more easily. And then more oxygen gets to their brain.”

Many people find the masks to be uncomfortable, and the hoses to be burdensome, but that is unwarranted, said Dr. Clionsky.

“When I was diagnosed with sleep apnea 18 years ago, I shared those same concerns,” he explained. “Unfortunately, only about 40% of people diagnosed with sleep apnea actually stick to wearing a CPAP mask and using their machines. But, those who do can see their AHI number go down to practically zero.”

Advances in technology have led to very quiet machines and have developed several mask options for patients today. Masks are worn either over the nose, under the nose, or over the nose and mouth. For side-sleepers, hoses can be attached to the top of the head with air delivered via a canula in the nose.

Better sleep leads to better sex

Dr. Clionsky said many people, especially men, don’t want to wear CPAP devices because it will make them feel old and sick, or they won’t feel sexy.

“I hear this all the time and tell my male patients that, if they have sleep apnea, chances are they’re not performing as well in bed as they should be,” he explained. “Nearly half of men who reach for the little blue pill or visit an erectile dysfunction clinic have sleep apnea. The reason they are having trouble in bed is due to not getting enough oxygen to the tips of all their blood vessels.

“So, if you increase the oxygen level, you’re actually going to have an easier time,” he added. “I joke with my patients that they shouldn’t wear their masks during sex anyway, but rather put them on when their ready to go to sleep.

“So, it’s not going to make you less sexy. In fact, your bed partner who is no longer hearing you snore all night is going to be much happier as a result,” said Dr. Clionsky. “You will wake up with more energy, possibly better thinking and a better ability to pay attention than you’ve had for years. Oxygen is critical to thinking and for flushing out toxins that develop in our brain when awake.”

To get people used to wearing a CPAP mask, Dr. Clionsky recommends they practice wearing it, unplugged from the hose, during the day, for about half an hour a day for one week.

“Look at the birds singing, listen to music or watch television,” he explained. “During the second week, do the same thing each day, but hook up the mask to your CPAP machine and turn it on. By that time, you are used to how it works and what it feels like to wear one when you are going to sleep. Our rates of success are between 70% to 80% rather than 40%.

“One thing I stress with patients is that oxygen is a good thing and, if you have sleep apnea, chances are strong you’re not getting enough of it,” he added. “The problem can be successfully treated and it will make a big difference in your brain health.”

The success of Charlie P.

In his book, Dr. Clionsky recalls the success story of a patient named Charlie P. When they first met, Charlie was 57 and having problems thinking and being creative. He felt very different from the way he had in the past.

“His wife was bitterly complaining about his inability to do the things he used to do, so we tested him and it appeared he had a mild case of dementia,” said Dr. Clionsky. “We also obtained a positron emission tomography (PET) image of his brain.

“The scan picks up on brain activity, sort of like Doppler radar. It’s unfortunate that we could not include a color copy of the scan in the book because it is a dramatic image,” he explained. “The scan showed Charlie’s brain was downregulated and it wasn’t operating enough because it wasn’t taking up a particular kind of tracer used in the PET scan. Basically, he didn’t have enough storms or activity going on.”

When a radiologist interpreted the scan, he noted it looked similar to what people exhibited with mild Alzheimer’s disease. Charlie was seen three times in a year and prescribed some type of Alzheimer’s medications; however, he didn’t like any of those. Additional tests and a second PET scan a year later showed the same results, so he dropped out of the program.

“About a year and a half later, Charlie shows up again with his wife and she announced that she’s got her husband back,” said Dr. Clionsky. “She said he was doing the things he used to do. Charlie told me he was writing poetry for the first time, which made him really happy because writing poetry was something he had always wanted to do.

“So we retested him and he took a third PET scan, but this time everything was completely normal. His brain activity showed it was where it should be,” he added. “Charlie gave credit to the sleep study he finally took, and the fact he committed to using the CPAP machine for his severe sleep apnea.

“He told me it was the best thing he ever did because his energy was increased and his thinking was better,” Dr. Clionsky explained. “He was the happiest guy. I saw him five years later and he was still doing great and using the CPAP every night.”

Sleep studies

In the past, researchers thought sleep apnea affected men more than women and, especially, people who were overweight. In fact, some of the original scales used by physicians to determine if someone should get a sleep study gave extra points for obesity and being male.

“If you were a guy who wears shirts with neck sizes 18 or higher, that also gave an extra point,” said Dr. Clionsky. “Today, we know that’s not necessarily the case.”

When tested, women actually experience sleep apnea as much as men, particularly when they are older.

“When women are younger, estrogen protects their airways to a greater extent,” he explained. “For older people, it has much more to do with the strength of the neck muscles. Then, when women go through menopause in their 40s and 50s, they lose that hormone and their breathing becomes very much like men.

“So, I encourage my female patients to get tested just as much as the men, and we are seeing great results for women, too,” said Dr. Clionsky. 

In the past, patients had to go into a special clinic for a sleep study. Today, most studies are conducted at home where patients are in more familiar surroundings. A doctor will prescribe the study, which is often covered by insurance and Medicare.

“You wear a device when you’re in bed just one night. The instruments vary from something that slips over a finger to things that go into your nose,” said Dr. Clionsky. “A new device which actually hooks into a Samsung cell phone has been approved by the Food and Drug Administration (FDA) for testing sleep apnea, which is a real breakthrough.

“With the newer technology for detecting sleep apnea, the likelihood that you have this condition if you are over 50, and our growing knowledge of its importance in dementia, every doctor should be paying attention to it,” he added. “If I ruled the world, everyone would have a sleep study every five years starting at age 50, the same way colonoscopies are recommended.”

Other causes of dementia

In their book, the Drs. Clionsky outline 20 factors that contribute to dementia. By being aware of what causes it, people can take steps earlier to limit their exposure or to take corrective action to delay the onset. The top three causes are:

1. Cardiovascular

“Smoking is a big no-no. Anyone who is still smoking cigarettes these days really should be looking at finding alternatives,” he explained. “It’s not so much for the cancer risk, which is important; but, what it does to blood pressure and the cardiovascular system is just as bad in many ways.”

2. Obesity

“It’s an epidemic in America,” said Dr. Clionsky. “People want to know what they should eat to reduce their risk of dementia. In reality, it’s not so much what you eat, but how much you eat.

“You get a slightly better outcome if you eat something healthier than fast food,” he explained. “When you’re paying attention to what you’re eating, the real effect is that you are also doing a better job of monitoring how much you eat and what you eat from a calories and weight perspective.”

The paunch people develop in midlife is really bad for cardiovascular health, too.

“Anything that is bad for your heart is also bad for your brain,” said Dr. Clionsky. “Work on reducing your weight to what is considered normal for your size because your body was designed for a certain weight.

“If you carry the weight it was designed for, then you won’t be putting excessive stress on your body,” he added. “But, if you’re carrying a lot of extra weight, it will have ramifications, like messing up your blood pressure and the ability to control sugar, which can result in hypertension and diabetes.”

3. Hearing loss

Surprisingly, hearing loss is also a cause for memory loss. It was one of the 12 factors discovered by the Lancet Commission.

“When we lose our hearing as we age, it’s often the result of wear-and-tear because we’ve been exposed to a lot of environmental noises, working in loud places, and things like rock-and-roll,” said Dr. Clionsky.

“But, when we lose our hearing, then our brain does not receive the background stimulation it needs. Because we don’t pay attention to it, we gradually lose our ability to hear things, like birds singing or the refrigerator motor turning off and on. It turns out our brains need that type of stimulation to stay alert.”

Hearing loss doesn’t have to be profound.  Even subtle hearing loss will cause a thinning of the surface of the brain in the auditory association areas, which are also connected to memory areas.

“As a result, your brain is losing more cells and connections than it should due to hearing loss,” said Dr. Clionsky. “Hearing loss also impacts the salience network, which operates in the background to look for things the brain thinks it should pay attention to.

“By looking at results of a functional MRI scan, we can see how the salience network is downregulated in people with hearing loss,” he explained. “That’s why when you give someone hearing aids, you not only correct their hearing loss, but their cognitive test scores also improve.

“You have changed the trajectory of their cognitive decline and reduced the risk of dementia,” he added. “Today, it’s even easier to get hearing aids because there are more brands and the technology is so much better than it was even five years ago.”

It’s for that reason Dr. Clionsky encourages people to get their hearing tested every five years. If someone wore hearing aids in the past, but didn’t notice an improvement, he suggested new technology may help them today.

Change or die

A pivotal chapter of Dr. Clionsky’s book addresses the fact that everyone wants to feel better, but few want to do the work or take action to get to that point.

“Change is the essence of life, but people often become really intransigent that they should have to change,” he explained. “Yet, if we know one thing more than anything else about life, it is that if we don’t constantly adapt, we die. That’s what makes us survive new environments and new ways.”

For example, about a year ago, Dr. Clionsky eliminated table salt from his diet. It was a difficult change because he loved salt so much his brother chided him by saying he would add salt to salt, if he could.

“One day, as I was automatically adding salt on my salad, I wondered what it would be like not to do this. So, I conducted a random experiment and stopped using table salt,” he explained. “I still cook with it, but I stopped adding it at the table. It is one of the factors that drives up blood pressure.”

Despite exercising vigorously and regularly, his blood pressure was still higher than it should be without medication.

“The first day or two, I really missed salt. After a week, I wasn’t missing it very much. After a while my salt sensors regulated to the point that I now I think twice before adding salt to anything,” said Dr. Clionsky.

“I will still eat a pretzel, but I have stopped adding salt to other foods before I taste them,” he added. “I realized this one little experiment helped me to think about other automatic habits. We constantly have opportunities to evaluate what we are doing and check our behavior to see what we can do to improve ourselves.”

Dementia prevention checklist

To help people self-evaluate their risk factors for developing dementia, whether or not they already have some symptoms, Dr. Clionsky offers a free dementia prevention checklist on his website. People can go through 25 questions online or download a PDF.

“Some questions you will be able to answer right away. Others might require a little research because they relate to some measures or lab tests your doctor may have done,” he explained. “But, the goal is to build self-awareness so you can see whether you are on target for avoiding dementia or off-target.

“The assessment helps you develop a roadmap to improve yourself as you go,” he added.

To view or download the checklist, visit www.braindoc.com/checklist-intro.

Techniques for combating dementia

The last part of the book is devoted to techniques people can implement to change their behavior.

“The section incorporates what we know about psychology to start making changes,” he explained.

“This is different from a new year’s resolution to ‘eat healthier’ and ‘get into better shape.’ Those typically crash-and-burn by February,” he added. “That happens because you didn’t do a good job of setting out exactly what you needed to do in a way that was achievable.

“And because your plan was poor, after a while, you tell yourself you can’t change or that’s just who you are,” said Dr. Clionsky. “The truth is that you could be someone different if you gradually approach the problem from a different perspective.”

He is in the process of rewriting the checklist so readers can generate a more personalized approach so they can focus on techniques they need to address immediately, eventually or not at all.

“It will be color-coded, so people will see green when they are on target, yellow when they’re close to the target, or red to indicate they are off target,” he explained. “That way you will know where to start. Then, after you’ve worked on some of those things, you can update your profile.”

Use your head to save your brain

Dr. Clionsky’s book “Dementia Prevention: Using Your Head to Save Your Brain” is available on Amazon and in other bookstores.

“It was published by John Hopkins Press, which is an academic publisher. So there were a lot of hoops we had to jump through to meet the rigorous scientific conditions they required,” he explained.

Although it is published by an academic press, it does not read like a textbook. It includes scientific information, but Dr. Clionsky worked to explain complex problems with easier-to-understand wording.

“Our goal was that anyone reading the book would feel like they were sitting in the room as Emily and I explained it to them,” he said. “All the material was developed by sitting one-to-one with patients and their families.

“Emily and I decided we aren’t getting any younger and we can’t see everyone, so we needed to get this information out to a wider audience,” he added. “The information is too valuable. We use the same techniques with our patients who already have dementia.

“If someone is already severely impaired by dementia, he or she is probably not coming back from that. However, for people in earlier stages of dementia, making these changes can actually reduce the decline over time,” said Dr. Clionsky. “Recent findings show that even people with Alzheimer’s disease who embrace changes to their lifestyle, have a much better chance of not digressing as fast as other people would.”

To connect with Dr. Clionsky, visit www.braindoc.com.

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