My father died of a cardiac arrest at age 44. I was 11 and prior to that had no real understanding of his health. I knew that he was diabetic, on insulin, slender (although he’d been chubby till his early 30s), exercised almost daily after work, and tried to eat carefully though even as a physician himself, seemed to not really have an understanding of how to do that. He lived the “American Dream” in Virginia as an immigrant from South Asia, working 60 hours per week, relatively isolated other than for his medical community. I’m now nearly 10 years older than his age at death and this extra decade often feels like a bonus as my own mortality looms.
My father‘s siblings eventually died only in their late 80s, but all had significant cognitive decline that rendered them completely dependent on their families in their final decade. Understanding that they likely had vascular dementia, as well as the gravity of my father‘s own metabolic and cardiovascular disease, motivated me to question my own dementia risk and what I might do to mitigate or delay its onset. Over the past 21 years I’ve had this same question from countless family members of patients with dementia, “Doctor, what can I do to try and not let this happen to me?”. Until recently, like most doctors, I would tell them there’s not much that one can do besides trying to eat well, sleep and exercise. I’d refer them to the MIND or Mediterranean diet but for the most part the sentiment was that dementia sucks but there’s not much we can do about it.
Modern Medicine owes us so much more
Dementia prevention isn’t easy, but it doesn’t have to be complicated. So why isn’t mainstream medicine doing more? The reasons are simple: 1) Pharmaceutical and medical device companies dictate the direction of physician knowledge (just visit a medical conference and you’ll see what I mean) and advocating for lifestyle change isn’t going to satisfy their shareholders. 2) Our insurance industry payment model is disease focused; there is no reimbursement code for dementia preventative health, so doctors have little time or incentive to learn about it. 3) It takes 10-20 years for medical research to reach the clinic unless the face of said innovation is social media savvy (kudos to you, Dr. Mosconi!). 4) Doctors are drowning in so much electronic medical records and insurance bureaucracy that they don’t have time to pursue independent learning for the sake of curiosity. 5) There is no standardized model of care or educational emphasis for Dementia Prevention established by professional neurologic societies (such as the American Academy of Neurology or the American Board of Psychiatry and Neurology).
The good news is that there are very actionable steps that patients can take. But when our traditional medical guidance is lacking, social media and influencers fill the gap and then the onslaught and legitimacy of advice is overwhelming and questionable. A patient could certainly fill their 24/7 with a fistful of supplements, tonics, exercises, breathwork, prescription medications, fasting/specialty diets without knowing if they’re making any progress or even knowing what their goals are.
This is where the concept of Medicine 3.0 (defined by Peter Attia, MD) comes in and can be pointed towards optimizing neurologic healthspan. We start with a simple question, what do you want from your last decades of life in terms of cognitive wellbeing and what does your physical health need to be to support that. Next we take objective stock of where you are now and come up with the strategy to get you where you want to be, accounting for age expected decline. By breaking it down and knowing what data to objectively track, we can prioritize which tactics are best for you and then layer on over time.
Breaking it down
In 2023 this is exactly what I did for myself. Getting to a granular level: I want to be cognitively able to be useful to my family and my community; I want to be someone they look to for advice and continue to be able to boss them around; I’d like to manage my finances independently; I want to feel grounded spiritually, have the concentration and attention to meditate; I’d like to remain a continuous learner and be able to hold meaningful conversations. Physically, I’d like to have an abundant porch garden where I can prop an easel and paint; I’d like to be able to hike a gentle hill for a mile with a 10lb pack; I’d like to be able to travel internationally; I’d like to cook for myself, cut vegetables and open lids. Along the way I’d like to achieve my dream retirement job of being a senior-yoga instructor. None of these are unattainable but it is a lot to ask of an 85-90 year old body, mind and brain so I have my work cut out for me.
Taking stock of the subjective physical inventory was easy. I was about 5-10 lb above my optimal weight. I thought I was relatively fit, exercising 4 to 5 times a week but nothing regimented. I’ve had chronic foot and back pain for about 5 years and have seen multiple PTs and chiropractors but never made any real progress. I love hiking, but I’m typically slow and max out at about a 25 pound pack after 6-7hours. Mild stress incontinence limited jumping or sudden sprints.
Spiritual/cognitive self assessment has been harder. I’ve never formally been diagnosed with ADHD but I’ve always compensated for poor attention and concentration by quick reasoning, fastidious lists and shaping my environment to maintain focus. A year from my last period and experiencing hot flashes, I empathized with the dozens of middle-aged women who have come to see me over the years for frustrating “brain fog“. Lifelong insomnia conditioned by decades of “all-nighters” in college and medical training was exacerbated by night sweats and racing mind. Perhaps most importantly, I saw a therapist and came to terms with the fact that my professional work as a physician within an industry driven by insurance and pharmaceutical profit was not aligned with my heart and was slowly killing me from the inside out.
From an objective standpoint, I started with the data I had at hand. My blood pressure was consistently healthy, below 120/80. An MRI at age 40 (for migrainous symptoms) had been normal so given the cost, I didn’t repeat it. I’d been resisting a statin in spite of high cholesterol/LDL, reassured by a coronary calcium score of zero at age 45. Advanced lipid testing suggested that I was in the 20% of the population with a markedly elevated risk of early heart and cerebrovascular disease. My hemoglobin A1c was still “normal” but post-meal blood sugars revealed significant spikes in spite of low-normal fasting blood sugar and insulin levels. I had a DEXA scan to check my body composition and saw that in spite of my regular exercise and a healthy vegetarian diet I was adequately nourished but quite under-muscled. My grip strength and heart rate recovery were low-average. My bone density was high-average. Additional labs indicated that although not yet hypothyroid, I was simmering towards Hashimoto thyroiditis, although most of my routine inflammatory markers were reassuring. From a fitness standpoint it was clear I had plenty of room for improvement in my muscle mass, strength and cardiovascular resilience and there was no time to lose given the rapid age-related decline after age 50 and menopause.
Working smarter, not harder
Addressing all of this simultaneously would’ve been too overwhelming so I needed to prioritize. When it comes to the brain, all roads lead to optimization of energy delivery, energy efficiency and how well the brain can manage its waste by-products. So, reviewing my challenges, it was clear that improving my metabolic health was paramount. The first step was to get a CGM, which I have worn now intermittently for nearly 2 years and it has been life-changing in terms of educating me to modify my behaviors and stay accountable. The next step was to commit to taking a statin on a daily basis and following an advanced lipid profile periodically. Having done the above for a month or two I added targeted time restricted eating ranging a few times a week.
Next, I asked my gynecologist to prescribe menopausal hormone replacement therapy and within weeks the hot flashes were gone. I took a sleep medicine course and learned how to implement behavioral modifications and started sleeping better and felt cognitively sharper. I’ve never been one to like to take “supplements” but the more I learned about our modern day food supply I became convinced that indeed we do need to supplement certain vitamins and minerals which serve as cofactors in so many of our neuronal processes. Additionally, I started targeted probiotics for glucose regulation and re-introduced lean meat and fish into my previous vegetarian diet in order to optimize my energy and protein consumption. I added an incrementally heavy functional weight training regimen to my daily jog/walk at least a few times a week, a “hard” cardio-interval training day once a week and have continued yoga once a week. I’ve adopted a pelvic floor exercise regimen and am now able to run and jump without concern. I found a chiropractor specialized in Dynamic Neuromuscular Stabilization and no longer live in fear of compounding my back or foot pain. Achieving my geriatric physical fitness goals will, by definition, by a lifelong endeavor but by working smarter, not harder, I have a clear strategy and tactics to follow to safely get there.
Perhaps most importantly, I took time to reflect on what was important to me spiritually. After 21 years of working and managing a neurology private practice, surrounded by colleagues and staff that I loved, I realized I needed to make a change professionally if I wanted to remain in alignment with what drew me to medicine in the first place. I love understanding people, what motivates them, what makes them happy and most of all, trying to find ways to optimize their well-being. While I was getting a glimmer of this in my former life, I always felt rushed and the scope of my work boxed me in. The administrative burden of fighting insurance and pharmaceutical companies was exhausting and unsustainable. In 2024, with a very heavy heart I said good-bye to my old colleagues and patients.
Onward
Like I said, this granular personalized approach doesn’t have to be complicated but it’s also not straightforward. My Dementia Prevention strategies won't be appropriate for everyone. Being a physician has allowed me to know how to prioritize and which specific tactics to pursue. For relatively little cost (other than for the DEXA and CGM all my testing has been covered by insurance) I have seen tremendous immediate benefit. I now feel stronger and more resilient, mentally, and physically. Most of all, I have agency over my wellbeing rather than feeling adrift. By defining my goals with clear parameters I have identified where I need to focus my efforts, how to build the social support necessary and where there is still work to be done.
There’s so much we can be doing to prevent dementia but even with my decades of experience as a neurologist, I didn’t previously know what to tell patients more specifically other than simple platitudes. I’m really excited about the work ahead because if we can stay curious and open minded, yet scientifically rigorous, there is much to learn and offer patients. Eventually though, one way or another, our time will be up and we’re all going down. My own life experience and being a neurologist certainly remind me that any day can bring the unexpected. But ultimately, I’d like anyone who knows me to say that she went down trying.
