Dementia

A study¹ of nearly 2000 older adults has found that eating a Mediterranean diet was associated with less risk of developing mild cognitive impairment or of transitioning from MCI to Alzheimer's disease. The third with the highest scores for Mediterranean diet adherence had a 28% lower risk of developing MCI compared to the third with the lowest scores, and of those who already had MCI, those with the highest scores for Mediterranean diet adherence had a 48% less chance of developing Alzheimer’s.

Another, similar-sized study², has found that those who adhered more strongly to a Mediterranean-type diet had a 40% risk reduction, and those who were very physically active had a 33% risk reduction of Alzheimer's -- doing both gave people a 60% reduction.

A Mediterranean-type diet is typically characterized by high intake of fish, vegetables, legumes, fruits, cereals and monounsaturated fatty acids; relatively low intake of dairy products, meats and saturated fats; and moderate alcohol consumption. Most of these components have been independently associated with reduced dementia risk. Let's look at them one by one.

Fruit & vegetables

A very large study³ of older adults found that those who ate fruits and vegetables daily reduced their risk of dementia by 30% compared to those who didn’t regularly eat fruits and vegetables. Another large, long-running epidemiological study⁴ found that those who drank three or more servings of fruit and vegetable juices per week had a 76% lower risk of developing Alzheimer’s disease than those who drank juice less than once a week. The benefit seemed greatest for those who carried the so-called “Alzheimer’s gene”.

This may not have anything to do with vitamin C. A five-year study⁵ involving nearly 3000 people has found that use of Vitamin C or E or both was not associated with a reduced risk of developing dementia or Alzheimer’s. However a study⁶ involving 4,740 elderly found the greatest reduction in both prevalence and incidence of Alzheimer's in those who used individual vitamin E and C supplements in combination. There was no significant benefit in these vitamins alone.

Of course, it is now well understood that taking vitamins as supplements is not the same as receiving them in food.

Two studies have come out in favor of a diet rich in foods containing vitamin E to help protect against Alzheimer's disease. One study⁷ involved 815 Chicago residents age 65 and older with no initial symptoms of mental decline, who were questioned about their eating habits and followed for an average of about four years. When factors like age and education were taken into account, those eating the most vitamin E-rich foods had a lower risk of developing Alzheimer’s, provided they did not have the ApoE e4 allele. This was not true when vitamin E was taken as a supplement. The effect of vitamin C was not statistically significant.

The other study⁸ involved 5,395 people in the Netherlands age 55 and older who were followed for an average of six years. Those with high intakes of vitamins E and C were less likely to become afflicted with Alzheimer's, regardless of whether they had the gene variation. This association was most pronounced for current smokers.

So beneficial effects of these vitamins may depend on genetics, smoking history, and possibly other lifestyle factors. But there are other valuable compounds common in fruits & vegetables. Another class of antioxidant chemicals, polyphenols, are now suspected. Polyphenols generally exist primarily in the skins of fruits and vegetables and are particularly abundant in teas, juices and wines.

A cell study⁹ also found that quercetin (a flavonoid with greater antioxidant and anticancer properties than vitamin C) protects against cellular damage. Quercetin is particularly abundant in apples (mainly in the skin, and especially the red ones). Other good sources are onions, blueberries and cranberries.

Another cell study¹⁰ found that compounds in blackcurrants (anthocyanins as well as polyphenols) strongly protect neuronal cells against the effects of amyloid-beta. Boysenberries contain the same compounds, and those that are darker are likely to be more potent.

The inconsistent findings regarding vitamins C and E may also have to do with the presence of folates. Data from the Baltimore Longitudinal Study of Aging¹¹ revealed that although those with higher intake of folates, vitamin E and vitamin B6 had a lower risk of developing Alzheimer’s, statistical analysis showed it was only folate consumption that was significant. Those who had at least 400mcg of folates a day (the recommended daily allowance) had a 55% reduction in risk of developing Alzheimer’s. Unfortunately, most people who reached that level did so by taking supplements, suggesting the difficulty of doing so through diet alone.

Folates are abundant in foods such as liver, kidneys, yeast, fruits (like bananas and oranges), leafy vegetables, whole-wheat bread, lima beans, eggs and milk; however, they are often destroyed by cooking or processing.

The benefits of folates probably has to do with its effect on homocysteine. A mouse study¹² indicates that increased levels of homocysteine are produced by low intake of folate and B vitamins, and impair cognition through microvascular changes. 

High levels of homocysteine are associated not only with deficiencies in vitamin B12 and folate, but also with smoking.

High levels of homocysteine were associated in one study¹³ with a more than five-fold increase in the risk for stroke, a nearly five-fold risk for vascular dementia, and almost triple the risk for Alzheimer's disease. Findings from the long-running Framingham study¹⁴ found people with elevated levels of homocysteine in the blood had nearly double the risk of later developing Alzheimer’s disease.

Moreover, evidence from a study¹⁵ using genetically engineered mice suggests that increased levels of homocysteine in the brain cause damage to nerve cells in the hippocampus -- which can be repaired when there is an adequate amount of folate, but not when there is a deficiency.

Omega-3 oils & fish

One of the clearest findings in this area has been the benefits of regularly consuming omega-3 oils, fish oil, and fish. Several epidemiological studies have indicated that regularly eating fish (at least once a week) reduces risk of dementia. More recently, two very large studies have come out in support. One very large study³ of older adults found that those who regularly consumed omega-3 rich oils, such as canola oil, flaxseed oil and walnut oil, reduced their risk of dementia by 60% compared to people who did not regularly consume such oils. Additionally, those who ate fish at least once a week had a 40% lower risk of dementia -- but only if they did not carry ApoE4 gene.

Moreover, for those who didn’t have the gene, regular use of omega-6 rich oils, but not omega-3 rich oils or fish, were twice as likely to develop dementia compared to those who didn’t eat omega-6 rich oils (e.g., sunflower or grape seed oil).

The second study¹⁶ comes from the famous long-running Framingham Heart Study, which found that those with the highest levels of DHA (an omega-3 polyunsaturated fatty acid found in relatively high concentrations in cold-water fish) had a 47% lower risk of developing dementia. Those with these levels tended to eat an average three fish servings a week, as well as an average of .18 grams of DHA a day. Those at lower levels ate markedly less fish.

There is also some suggestion that omega-3 oils might help slow the progression of dementia. A Swedish study¹⁷ found that, although fatty acids DHA and EPA didn't slow cognitive decline in those with mild-to-moderate Alzheimer’s, they did slow decline in those with very mild cognitive impairment (a frequent precursor of dementia). It's been suggested that anti-inflammatory effects are an important reason for the benefit, why might explain why benefits only occur in the very early stages, when levels of inflammation seem to be higher.

Similar results were more recently reported¹⁸ from a large 18-month trial. This one, however, suggested that genetic status might be a factor -- that those without the “Alzheimer’s gene” ApoE4 might benefit even if impairment had progressed to mild-to-moderate Alzheimer’s.

There are a number of reasons why DHA might help brains.

A study involving genetically engineered mice¹⁹ has found that a diet high in DHA dramatically slowed the progression of Alzheimer's by cutting the harmful brain plaques that mark the disease. An earlier study²⁰ showed that DHA protected against damage to the synaptic areas where brain cells communicate and enabled mice to perform better on memory tests. More recent research²¹ has revealed that DHA increases the production of LR11, a protein that is found at reduced levels in Alzheimer's patients and which is known to destroy the protein that forms the plaques associated with the disease.

Food sources of omega-3 fatty acids include fish such as salmon, halibut, mackerel and sardines, as well as almonds, walnuts, soy, flaxseed, and DHA-enriched eggs. These fish have high levels of DHA because they consume DHA-rich algae. Because these fishes' oiliness makes them absorb more mercury, dioxin, PCP and other metals, a less risky yet more costly strategy is to consume fish oil or purified DHA supplements made from algae.

Possible benefits of wine, tea, and coffee

There have been a number of reports that moderate alcohol consumption (generally defined as 1 drink or less per day for women and 1-2 drinks or less per day for men) may help reduce your risk of developing dementia, and a 2008 review of 44 studies²² supported this conclusion. 

However, given that alcohol has known negative effects on the brain, no one is recommending that non-drinkers take up the habit! All one can say is that there's no reason to alter your habits if you are a moderate drinker. On the other hand, if you drink more than this, you are probably best to knock it back to this level.

However, the evidence suggests that it is wine rather than alcohol in general that is beneficial for the brain. A large Danish study²³ found that those who drank wine occasionally in the 1970s had a lower risk of developing dementia in the 1990s (when participants were 65 or older). However, occasional beer drinking was associated with an increased risk of developing dementia. But we cannot draw too hard & fast a conclusion from this, as eating habits were not investigated, and research suggests that wine drinkers may have better dietary habits than beer and liquor drinkers. Moreover, a very large study of older adults³, that found a significant effect of some dietary factors, found no effect of wine.

There are, however, some good reasons for believing regular drinking of red wine may help the aging brain. Red grapes contain several polyphenols that have been shown to significantly reduce cognitive deterioration in genetically engineered mice, by preventing the formation of amyloid beta. One of these is resveratrol; the others are catechin and epicatechin. Resveratrol was much vaunted when its effects were first discovered, but unfortunately it requires extremely high doses. The more recent discovery²⁴ of the catechins is much more exciting, as they appear to be effective at much lower doses. The catechins are also abundant in tea and cocoa.

Tea, most particularly green tea, has also been found²⁵ to inhibit the activity of enzymes associated with the development of Alzheimer's Disease. Green tea also obstructed the activity of beta-secretase.

These inhibitory properties were not found in coffee. However, a large, long-running Finnish study²⁶ has found that those who were coffee drinkers at midlife had lower risk for dementia and Alzheimer’s later in life compared to those drinking no or only little coffee midlife. The lowest risk was found among moderate coffee drinkers (drinking 3-5 cups of coffee/day).

Restricting your calories

There has been some talk that calorie-restricted diets might help prevent Alzheimer's. So far, the only indications have come from experiments with genetically engineered mice. While there have been a number of studies providing evidence that high cholesterol, obesity, and other cardiovascular risk factors increase the likelihood of Alzheimer’s, it is decidedly premature to say whether calorie-restricted diets would benefit humans. Particularly since one of the early signs of Alzheimer's is weight loss. So it is certainly not recommended that people severely restrict their diets. More useful is removing certain food types (e.g., the "bad" oils; sugar -- there is some evidence that Alzheimer's may be a type of diabetes), and increasing consumption of others (fish, "good" oils, fruit & vegetables).

There may also be a genetic link. A four-year study²⁷ of nearly 1000 older adults found that among those who carried the ApoE e4 gene, those who consumed the most calories had a 2.3 times greater chance of developing Alzheimer’s compared to those who ate the fewest calories. But calories weren't a factor for those without the gene.

Cholesterol

A study²⁸ involving nearly 10,000 people who underwent health evaluations between 1964 and 1973 when they were between the ages of 40 and 45, has found that those with total cholesterol levels between 249 and 500 milligrams were one-and-a-half times more likely to develop Alzheimer's disease than those people with cholesterol levels of less than 198 milligrams. People with total cholesterol levels of 221 to 248 milligrams were more than one-and-a-quarter times more likely to develop Alzheimer's disease. High cholesterol increased risk regardless of midlife diabetes, high blood pressure, obesity, smoking and late-life stroke.

A review²⁹ of autopsy cases of patients over 40 years old found that high blood cholesterol levels were correlated with the presence of amyloid deposits in the brain in the youngest subjects (aged 40-55).

An analysis³⁰ of data on 1037 older women who had participated in a clinical trial of hormone replacement therapy found that high cholesterol levels increase the risk of cognitive impairment.

A large-scale Finnish study³¹ following 1449 men and women over 21 years found that raised systolic blood pressure and high serum cholesterol concentration, particularly in combination, in midlife, increase the risk of Alzheimer's disease in later life. Raised diastolic blood pressure had no significant effect.

However, the long-running, large-scale Framingham Heart study³² found that, after adjustment for age, sex, APOE genotype, smoking, body mass index, coronary heart disease, and diabetes, there was no significant association between AD risk and cholesterol level.

Previous studies suggesting that fat may be involved in the development of dementia and Alzheimer’s disease have been contradicted by a new study³³ involving over 5,000 elderly people over a period of six years. The study found no correlation between fat and cholesterol intake and risk of dementia, and no evidence for a reduction in risk for those taking cholesterol lowering medication.

A cell study³⁴ provides more understanding of why there might be a link between cholesterol and Alzheimer's disease. The study found that proteins which help control cholesterol levels in arterial walls were also present in neurons, and when the genes for these proteins were over-expressed, production of amyloid beta protein fell. The finding suggests a new approach to slowing Alzheimer’s. The study also showed that the apoE protein is extremely good at regulating cholesterol removal from neurons — the gene for this protein is a well-known genetic risk factor for Alzheimer's.

Diabetes

A large Swedish study³⁵ has found that men with low insulin secretion capacity at age 50 were nearly one-and-a-half times more likely to develop Alzheimer’s disease than men without insulin problems. The risk was strongest in those who didn't have the APOE4 gene. Another large study³⁶ found that diabetes was related to a significantly higher risk of developing amnestic mild cognitive impairment in older seniors (average age 76), after controlling for other risk factors. And a large study³⁷ of post-menopausal women (mean age 67 years) found that those with poor blood sugar control were four times more likely to develop MCI or dementia. Findings³⁸ from the long-running Religious Orders Study also support a link between diabetes and an increased risk of developing Alzheimer's disease.

Evidence from a mouse study³⁹ suggests that diabetes might increase risk because elevated blood glucose levels interact with beta amyloid in a way damaging to blood vessels in the brain. In fact it has been suggested that Alzheimer’s could be considered a third form of diabetes. Another study⁴⁰ provides evidence that amyloid oligomers remove insulin receptors from nerve cells, rendering those neurons insulin resistant. Another mouse study⁴¹ suggests that low levels of insulysin, an enzyme that degrades insulin, are a factor. The enzyme, it seems, also degrades amyloid-beta peptides, and even a partial decrease in insulysin activity was found to raise amyloid-beta peptide levels in the brain.

Obesity

A review⁴² of 10 international studies published since 1995, covering just over 37,000 people, has found that obesity increased the relative risk of dementia by an average of 42% compared with normal weight. Being underweight increased the risk by 36%. For Alzheimer's Disease and vascular dementia, specifically, obesity was an even more significant risk: 80% and 73%, respectively. With regards to Alzheimer’s, obesity was more likely to be a risk factor for women, but men were more affected when it came to vascular dementia.

A very large study⁴³ that measured abdominal fat at age 40 to 45 and dementia occurrence some 36 years later, found that those with the highest amount of abdominal fat were nearly three times more likely to develop dementia than those with the lowest amount of abdominal fat. Having a large abdomen increased the risk of dementia regardless of overall weight and existing health conditions, although being obese as well did increase the risk. Those more likely to have abdominal obesity, were women, non-whites, smokers, people with high blood pressure, high cholesterol or diabetes, and those with less than a high school level of education. And another large study⁴⁴ found that those who at 40 were obese, or had high blood pressure, or high cholesterol levels, were twice as more likely to develop dementia by the age of 60. Having all three of these risk factors increased their chances six-fold.

And just to be really scary, when⁴⁵ genetically engineered mice were fed a diet rich in fat, sugar and cholesterol for a mere nine months (although that is, of course, much longer for a mouse than it is for us!), they developed a preliminary stage of Alzheimer's pathology in their brains, suggesting that a ‘fast food’ diet could be a contributory factor in those with the Alzheimer’s gene.

Physical exercise & fitness

A number of studies have found that physical fitness reduces the risk of dementia. One way physical exercise can help fight dementia is through its ability to grow neurons in the hippocampus. This is well-established in rodent studies, and has been confirmed in small human studies. One such study⁴⁶ found the association between physical fitness and hippocampus size was specifically associated with performance on certain spatial memory tests. Another⁴⁷ found that those with early Alzheimer's disease who were less physically fit had four times more brain shrinkage when compared to normal older adults than those who were more physically fit, suggesting the value of physical fitness extends to slowing down the progression of the disease.

Another reason for exercise to prevent dementia is through its effect on cardiovascular fitness, and a reasonably large four-year study⁴⁸ did indeed find that the most active (top third) were significantly less likely to develop vascular dementia than the least active (bottom third). Interestingly, no such association was found with Alzheimer’s disease. However, at least two large studies have found a significantly reduced risk of dementia in those who had higher levels of fitness⁴⁹ or exercised three or more times a week⁵⁰. It may be that exercise has a greater effect on vascular dementia, but many cases of Alzheimer's dementia are actually mixed dementia, with a vascular component.

Genes

Several genes have been implicated in Alzheimer's, but the big one is the e4 allele of the ApoE gene (on chromosome 19). This variant is found in about a quarter of the population.

Having it doesn't mean you are foreordained to develop Alzheimer's, but it certainly increases the risk substantially. The risk goes up considerably more if both of your genes are the e4 variant (remember you inherit two: one from each parent).

It also increases if you have both the ApoE-e4 and the D10S1423 234-bp allele (found on chromosome 10). The combined risk of these two gene variants has been described as being greater than the increased risk of lung cancer caused by smoking¹. Chromosome 10 has also been implicated in setting the age at which it begins, for both Alzheimer's and Parkinson's diseases, in those genetically disposed.

Another gene that has been linked to Alzheimer's is the KIBRA gene (on chromosome 5) — carriers of the T-allele have a 25% lower risk of developing Alzheimer's compared to those who carry the C-allele².

It does seem that having the right, or wrong, genes is more important than we believed. Data from the Swedish Twin Registry³, involving nearly 12,000 people aged 65 and older, estimated that genetic influence accounted for 79% of Alzheimer's risk, with 95% probability of being within the range 67 to 88%.

But it's not just a matter of genes. Not everyone with the 'wrong' genes will develop dementia, and not everyone who develops dementia has the wrong genes. There are a number of lifestyle actions that affect it.

Even the genetic picture is not as simple as it sounds. One study⁴, for example, found indications that having a mother who had Alzheimer's is more significant than father's status. Data from the long-running Framingham Heart Study has found⁵ that cognitive impairment is more likely in those whose who have the ApoE ε4 gene — but only if they had a parent with dementia (particularly if it was Alzheimer's). There was no effect of parental dementia in those who didn’t have the ApoE ε4 gene.

For those who carry the “Alzheimer’s” APOE-4 gene, and those who later develop dementia, there is an association between smaller head size and lower educational achievement⁶. In other words, having both a small head size and low educational achievement in early life makes it more likely that a person will develop Alzheimer’s — probably because of their lack of cognitive reserve.

Cardiac & Blood Pressure Problems

A very large study⁷ found that those with atrial fibrillation, regardless of age, were 44% more likely to develop dementia, with those younger than 70 particularly at risk (130% more likely to develop dementia). Previous studies have connected atrial fibrillation with vascular dementia; this finding extends it to all dementia types.

Another, smaller, study⁸ (135 patients) found that memory declined significantly faster in those with high blood pressure or atrial fabrillation.

Atrial fibrillation, the most common heart rhythm problem, has a strong genetic link, and is also a risk factor for stroke.

Smoking

A very large seven-year study⁹ found that older adults who smoked were 50% more likely to develop dementia than people who had never smoked or no longer smoked. Smoking did not increase the risk for those with the Alzheimer’s gene apolipoprotein E4, but for those without the gene, smoking increased the risk by nearly 70%. Another large study¹⁰ found that heavy smokers developed the disease 2.3 years sooner, while heavy drinkers developed Alzheimer’s nearly 5 years earlier than those who were not. Those with the APOE e4 gene developed the disease three years sooner than those without the gene variant. These three risk factors were additive — those with all three developed the disease 8.5 years earlier than those with none of the risk factors.

A large national study¹¹ also found that exposure to second-hand smoke also increases your risk.

Depression, stress & anxiety

Several studies¹² have found evidence that depression, high level of stress or anxiety, and even loneliness, increase the risk of later developing dementia.

Other Possible Risk Factors

Findings from a study¹³ using genetically engineered mice suggests that people genetically predisposed to Alzheimer's disease or with excessive amounts of beta amyloid in their brains are at increased risk of developing the disease earlier if they receive high concentrations of oxygen, for example during or after surgery.

A large long-running study¹⁴ has found that women with both the lowest and the highest levels of thyrotropin (a hormone secreted by the pituitary gland that helps regulate thyroid gland function) had more than double the risk of developing Alzheimer's disease. No such association was found in men.

Stimulating activities

A 5-year study¹ involving 488 people age 75 to 85 found that, for the 101 people who developed dementia, the greater the number of stimulating activities (reading, writing, doing crossword puzzles, playing board or card games, having group discussions, and playing music) they engaged in, the longer rapid memory loss was delayed. Similarly, a study² involving 1321 randomly selected people aged 70 to 89, of whom 197 had mild cognitive impairment, has found that reading books, playing games, participating in computer activities or doing craft activities such as pottery or quilting was associated with a 30 to 50% decrease in the risk of developing memory loss compared to people who did not do those activities.

Moreover, two activities during middle age (50-65) were also significantly associated with a reduced chance of later memory loss: participation in social activities and reading magazines. The value of social activities is consistent with another, small, study³ that found that social networks, like education, offers a 'protective reserve' capacity that spares individuals the clinical manifestations of Alzheimer's disease. As the size of the social network increased, the same amount of Alzheimer’s pathology in the brain had less effect on cognitive test scores. For those without much pathology (plaques and tangles), social network size had little effect on cognition.

This supports another study⁴ involving 469 people aged 75 and older, that found that those who participated at least twice weekly in reading, playing games (chess, checkers, backgammon or cards), playing musical instruments, and dancing were significantly less likely to develop dementia. Although the evidence on crossword puzzles was not quite statistically significant, those who did crossword puzzles four days a week had a much lower risk of dementia than those who did one puzzle a week.

Similarly, a study⁵ of 700 seniors found that more frequent participation in cognitively stimulating activities, such as reading books, newspapers or magazines, engaging in crosswords or card games, was significantly associated with a reduced risk of Alzheimer’s disease. On average, compared with someone with the lowest activity level, the risk of disease was 47% lower for those whose frequency of activity was highest.

In the first comprehensive review⁶ of the research into 'cognitive reserve', which looks at the role of education, occupational complexity and mentally stimulating activities in preventing cognitive decline, researchers concluded that complex mental activity across people’s lives almost halves the risk of dementia. All the studies also agreed that it was never too late to build cognitive reserve. The review covered 29,000 individuals across 22 studies.

A review⁷ of research on the impact of cognitive training on the healthy elderly (not those with mild cognitive impairment or Alzheimer's disease), has found no evidence that structured cognitive intervention programs affects the progression of dementia in the healthy elderly population.

Post-mortem analysis of participants in a large, long-running study⁸ has provided more support for the idea that mental stimulation protects against Alzheimer’s. The study found a cognitively active person in old age was 2.6 times less likely to develop dementia and Alzheimer’s disease than a cognitively inactive person in old age. This association remained after controlling for past cognitive activity, lifetime socioeconomic status, and current social and physical activity. Frequent cognitive activity during old age was also associated with reduced risk of mild cognitive impairment.

Research involving genetically engineered mice⁹ has found that mice whose brains had lost a large number of neurons regained long-term memories and the ability to learn after their surroundings were enriched with toys and other sensory stimuli, pointing to the importance of maintaining cognitive stimulation as long as possible. Similarly, another mouse study¹⁰ found that short but repeated learning sessions can slow the development of those hallmarks of Alzheimer's, beta amyloid plaques and tau tangles. And another¹¹ found that an enriched environment, with more opportunities to exercise, explore and interact with others, dramatically reduces levels of beta-amyloid peptides.

Education & iq

A study¹² involving some 6,500 older Chicago residents being interviewed 3-yearly for up to 14 years (average 6.5 years), has found that while at the beginning of the study, those with more education had better memory and thinking skills than those with less education, education was not related to how rapidly these skills declined during the course of the study. The result suggests that the benefit of more education in reducing dementia risk results simply from the difference in level of cognitive function.

Another study¹³ has come out supporting the view that people with more education and more mentally demanding occupations may have protection against the memory loss that precedes Alzheimer's disease, providing more evidence for the idea of cognitive reserve. The 14-month study followed 242 people with Alzheimer's disease, 72 people with mild cognitive impairment, and 144 people with no memory problems.

Another study¹⁴ has come out confirming that people with more years of education begin to lose their memory later than those with less education, but decline faster once it begins. Researchers note that since the participants were born between 1894 and 1908, their life experiences and education may not represent that of people entering the study age range today.

A study¹⁵ of 312 New Yorkers aged 65 and older, who were diagnosed with Alzheimer's disease and monitored for over 5 years, found that overall mental agility declined faster for each additional year of education, particularly in the speed of thought processes and memory, and was independent of age, mental ability at diagnosis, or other factors likely to affect brain function, such as depression and vascular disease. It’s suggested this may reflect the greater ability of brains with a higher cognitive reserve to tolerate damage, meaning the damage is greater by the time it becomes observable in behavior.

The Nun Study¹⁶ found that nuns who completed 16 or more years of formal education or whose head circumference was in the upper two-thirds were four times less likely to be demented than those with both smaller head circumferences and lower education.

Post-mortem study¹⁷ of the brains of 130 participants in the Religious Orders Study found that the relationship between cognitive performance and the number of amyloid plaques in the brain changed with level of formal education. The more years education you had, the less effect the same number of plaques had on actual cognitive performance. It’s worth noting that this considerable difference was observed in a population where even the least educated had some college attendance; presumably the difference would be even more marked in the general population.

A long-running Finnish study¹⁸ has found that compared with people with five or less years of education, those with six to eight years had a 40% lower risk of developing dementia and those with nine or more years had an 80% lower risk. Generally speaking, people with low education levels seemed to lead unhealthier lifestyles, but the association remained after lifestyle choices and characteristics such as income, occupation, physical activity and smoking had been taken into account.

An analysis of high school records and yearbooks from the mid-1940s¹⁹, and interviews with some 400 of these graduates, now in their 70s, and their family members, has found that those who were more active in high school and who had higher IQ scores, were less likely to have mild memory and thinking problems and dementia as older adults.

An analysis²⁰ of 184 people with dementia found that the mean age of onset of dementia symptoms in the 91 monolingual patients was 71.4 years, while for the 93 bilingual patients it was 75.5 years — a very significant difference.

A study²¹ of 122 people with Alzheimer's and 235 people without the disease found that people with Alzheimer's are more likely to have had less mentally stimulating careers than their peers who do not have Alzheimer's.

A study²² of 173 people from the Scottish Mental Survey of 1932 who have developed dementia has found that, compared to matched controls, those with vascular dementia were 40% more likely to have low IQ scores when they were children than the people who did not develop dementia. This difference was not true for those with Alzheimer's disease. The findings suggest that low childhood IQ may act as a risk factor for vascular dementia through vascular risks rather than the "cognitive reserve" theory. 

Movement with Meaning: A Multisensory Program for Individuals in Early-Stage Alzheimer's Disease

Those of us in the field of dementia care are reexamining our philosophical beliefs and exploring practical, hands-on approaches in our relationships with individuals living with Alzheimer's disease. We are creating innovative programs and developing a new framework for preserving the emotional health, autonomy, and dignity of those who need us to walk hand in hand with them, witnessing the process of their experiences with empathy and respect.

Movement with Meaning is one such program. Designed for persons in the early stage of Alzheimer's disease, Movement with Meaning reinforces the remaining strengths and abilities of people with dementia by using a multisensory approach that stimulates all five senses. Practical and interactive by nature, the curriculum is ideal for physical therapists, recreational instructors, and activity directors in adult day centers and assisted living facilities, as well as health care professionals who are senior trainers, music or dance therapists.

As the mind begins to slowly unravel, the body becomes the refuge - the container - the ground - the point of reference. In a Movement with Meaning class, the multisensory activities are divided into five segments that create a choreography of movements in which short, repetitive exercises increase a sense of well being. The program introduces simple breathing techniques, poetry, music, movement exercises (bilateral integration exercises and yoga postures), and sensory activities. Once the person with Alzheimer's disease experiences a sense of his or her inner landscape, anxiety and confusion begin to subside. Movement with Meaning provides an opportunity for the participants to recognize the abilities and talents lying dormant behind the disease and find a new path to connect and communicate with each other and their families.

What an opportunity we have with the advent of early diagnosis. So why wait? Because the long-term memory is not affected in the early stage of Alzheimer's disease, these memories are preserved. I have found that repetition is an effective method for not only retrieving these memories, but as an essential tool in a Movement with Meaning class.

A study published in the American Journal of Alzheimer's Disease and other Dementias (Jan-Feb, 2004 issue) shed light on the effectiveness of repetitive work on maintaining functional levels in Alzheimer's disease patients. In the Adapted Work Program participants were given jobs that included packaging, shredding, folding laundry, stamping and sending our mailings. The program was closed due to budget cuts in funding. The participants were transferred to a traditional day care program which included activities such as bingo, ceramics, music, and current events. Before moving to the traditional day care setting the participants were assessed with the MMSE (Mini-Mental Status Exam), the Cognitive Performance Test, and the Geriatric Depression Scale. And then reassessed again in 4 months, after being at the traditional day care facility. The MMSE and the Cognitive Performance Test scores were lower than expected. All the spouses of the participants reported declines in Activities of Daily Living. The conclusion of the study stated that activities that involve repetitive, sequencing skills promote better self-care at home than traditional day care environments. As mentioned above Movement with Meaning is divided into five segments, with a thematic thread that reinforces the continuity of the program.

The first segment in a Movement with Meaning class is "Centering through Breathing." When an individual with Alzheimer's disease experiences disorientation, has difficulty remembering names, or finding the right word, this can be unsettling and cause anxiety. The antidote to help diminish anxiety is mindful breathing. Once the mind is calm and relaxed concentration will follow. In his book, "Your Memory: How it Works, and How to Improve it," K. Higbee documents that high anxiety interferes with attention and concentration. Therefore, it is imperative to establish an environment that promotes a peaceful inner state. When participants feel relax and calm the ability retrieve firmly rooted songs, prayer, and poems begin to surface.

The second segment in a Movement with Meaning class is "Learning by Heart." The participants memorize a short poem or song. Poems and songs that were learned early in life are stored in the long-term memory and remain accessible to the person with early-stage Alzheimer's disease. Repetition is the method for learning a new poem or song. The rhythm patterns and cadence in each poem or song creates an atmosphere that is safe and nonthreatening and brings something to the lives of the participants that is representative of what was there before the disease. Included in the second segment is the use of visualization techniques to expand on the imagines evoked by a poem or song. Visualization increases concentration because it creates focus on the more subtle "mental pictures" and "feelings" of a poem or song.

The third segment is a Movement with Meaning class (A Delicate Balance and Nice and Easy Yoga) including both bilateral integration exercises and yoga postures. Problems with balance and coordination begin to occur in early-stage Alzheimer's disease. Muscles love rhythmic movement. By satiating the body with repetitive bilateral exercises or yoga postures, participants are not only integrating both left and right hemisphere of the brain but are also increasing their spatial awareness, balance, and coordination. These exercises and postures are similar to Tai Chi in that they help the participant identify the body's midline - the median plan where the left and right sides of the brain and body cross or overlap.

In a study in the Winter 2003-2004 issue of Generations an article titled: "Balance Intervention to Prevent Falls," addresses the importance of exercises that include flexibility, balance, and sensory awareness. A multidimensional program is important for fall reduction. By aligning the body with the earth, a nonverbal statement is made: "I know where my body is in time and space." By incorporating a physical component in a Movement with Meaning class, the transition from the cadence of a poem or the melody of a song is experienced as part of a continuum, unfolding a choreography of movements with a theme and purpose.

The fourth segment is a Movement with Meaning class, "A Sense of Timing," which introduces music and rhythmic exercises to help the participants integrate and embody a poem or song. The rhythm patterns are synchronized with the cadence and melody of the poem or song. Rhythmic instruments such as chimes, drums, bells, and claves are nonverbal ways of communicating. The repetition of a beat or dance evolves an inner musical sense, and inner timing. Without thinking, the participants begin to tap their feet or sway their bodies from side to side. Studies in Germany reveal that when individuals with Alzheimer's disease participate in music therapy that include rhythm instruments sensory and motor integration are promoted.

The last segment is a Movement with Meaning class, "Reawakening the Senses," devoted to using the senses of smell, taste, and touch, with attention to color, shape, and texture. Exploring the senses allows individuals with Alzheimer's disease to gain access to their own unique internal landscape. We make sense of the world through our senses. The body is the primary receptor and container of experience. Appropriate sensory stimulation is a main avenue to awakening latent memories, as well as supporting existing functional abilities.

When the elements Movement with Meaning are put together in a daily program, attention is refocused back to the body of the person with Alzheimer's disease. For whatever was lost in the cognitive realm can be recalled through the senses. As one participant in a Movement with Meaning stated when asked what she thought about the program, "I have enough to hold on to."

I'll ask the same question again: So why wait? The time is now, in the early stage, to reinforce remaining strengths and abilities. The time is now, while the individual is aware of his or her personal biography, to investigate the sense of the individual's inner landscape is changing. The time is now to create an environment that strives to preserve the identity and dignity of each individual affected by Alzheimer's disease.

Barbara Larsen, M.A., Ed.
Creator & Author, Movement with Meaning
P. O. Box 2636
Nevada City, CA 95959
blarsen@nccn.net