2020: A Bad Year For Your Brain?

By Julie Russell, MA


On a global level, this has been a year of extraordinary change to daily life, an historic period during which humankind connected through a collective state of worry, isolation, and adaptation to the spread of the COVID-19 virus. While many have been directly affected by the virus, there are many more who live in fear that they will become personally affected before adequate treatment is available.

In addition to these worries about the virus, many families face significant stress related to:

• job security or loss
• managing working from home and remote schooling for children
• marital discord
• lack of social engagement with friends and loved ones
• poor quality sleep
• changes to eating habits
• disrupted exercise routines
• excessive screen time
• distress from headlines of political and social unrest

Taken together, these life stressors and lifestyle changes may be taking a significant toll on many people’s physical, psychological, and cognitive health.

How This Affects Your Brain
When life stressors and lifestyle changes co-occur and persist, it causes excessive release of stress hormones that can lead to inflammation in the body, which can eventually spread to the brain and adversely affect multiple domains of cognitive function1. Hormonal changes associated with chronic stress along with inflammation in the brain can impact both the reward-related brain regions that result in reduced motivation and loss of pleasure2 and reduced volume of the region of the brain involved in learning and memory3. This can result in noticeable difficulty concentrating, planning, problem-solving, reasoning, and making decisions, which then feeds an unrelenting cycle of increased anxiety and depression, and continues the release of stress hormones that maintains inflammatory processes1,2,3.

The stress response can manifest very differently on an individual level, but many will report symptoms such as headache, increased pain in the body, gastrointestinal changes, weight change, increased blood pressure, fatigue, irritability, and clouded thinking4. While these ongoing life challenges that we collectively face may feel overwhelming, there are numerous ways we can halt and even reverse their health-related and create the conditions for resilience and cognitive recovery5.

What Can You Do?
The best place to start is to prioritize rest, not just in the form of good sleep hygiene (see tips for better sleep), but also in the form of taking a rest from screen time. Excessive screen time impacts attention, energy, mood, and circadian rhythm6. As an alternative, consider listening to music after waking up and before bed rather than turning on a screen. Take a refreshing walk outdoors and stretch on a daily basis; the minimum recommendations for physical activity are 30 minutes a day, 5 days a week7. Ditch the junk food that leaves you feeling energy depleted and eat more foods from the MIND diet that has been shown to protect the vascular system and cognitive health.

Prioritizing better rest, less screen time, regular walks, and improved eating habits, will gradually reduce the stress response cycle and allow the body and the brain to recover from inflammation. Persistence is the key to recovery and for developing resilience.

Our minds and bodies are designed to adapt to the adversities we face, and the basic choices we make each day will either help or hinder our adaptability. Protecting and promoting our brain health has never been more important than it has been this year. While we may all be socially distanced, we are going through this together, and we can collectively adapt and recover.


References

  1. (1) Ménard, C., Pfau, M., Hodes, G. et al. Immune and Neuroendocrine Mechanisms of Stress Vulnerability and Resilience. Neuropsychopharmacol 42, 62–80 (2017). https://doi.org/10.1038/npp.2016.90
  2. (2) Felger, J., Li, Z., Haroon, E. et al. Inflammation is associated with decreased functional connectivity within corticostriatal reward circuitry in depression. Mol Psychiatry 211358–1365 (2016). https://doi.org/10.1038/mp.2015.168
  3. (3) Lupien SJ, Juster R-P, Raymond C, Marin M-F. The effects of chronic stress on the human brain: from neurotoxicity, to vulnerability, to opportunity. Frontiers in neuroendocrinology 49, 91-105. (2018). https://doi:10.1016/j.yfrne.2018.02.001
  4. (4) Wekenborg MK, von Dawans B, Hill LK, Thayer JF, Penz M, Kirschbaum C. Examining reactivity patterns in burnout and other indicators of chronic stress. Psychoneuroendocrinology 106, 195-205. (2019) https://doi:10.1016/j.psyneuen.2019.04.002
  5. (5) Ortiz JB, Conrad CD. The impact from the aftermath of chronic stress on hippocampal structure and function: is there a recovery? Frontiers in neuroendocrinology 49, 114-123. (2018). https://doi:10.1016/j.yfrne.2018.02.005
  6. (6) https://www.rallyhealth.com/health/unexpected-effects-screen-time
  7. (7) https://www.cdc.gov/physicalactivity/basics/adults/index.htm










Should We Screen Older Adults for Cognitive Impairment?


The US Preventative Services Task Force (USPSTF) recently addressed this question and determined that there is “insufficient evidence to assess the balance of benefits and harms” associated with such screening. In effect, they could not conclude if it was helpful, harmful, or neither.

However, the question, and the conclusion of the USPSTF, both lend themselves to widespread misinterpretation. This brief summary takes a precise look at the issue and offers some clarity.

First of all, the task force defines “screening” in a very specific way. In this case, it means assessing the cognition of  individuals with no clear signs or symptoms of a cognitive deficit. There is essentially no debate that doctors should evaluate the cognitive health of patients who do show signs of impairment; the USPSTF would agree. But “evaluating symptoms” is not the same as “screening” and is therefore, not a part of this discussion.


Assessing subjects with no symptoms is “screening” while assessing subjects who do have symptoms is “case finding”. This USTFPS opinion relates strictly to screening.

Second, the term cognitive impairment covers a wide range of disability from very mild (a subtle sense that thinking skills are becoming slower or less vital) to severe (full dementia including a loss of ability to care for oneself). The broad range of severity in this definition is problematic because, as just discussed, the term “screening” only applies to those “older adults” at the extreme mild end of this spectrum. As such, the posed question contains an inherent flaw. Either “screening” is the wrong word because it does not apply to many along the spectrum of cognitive impairment, or the term “cognitive impairment” must be precisely qualified to include only asymptomatic subjects. Otherwise, a sensible answer cannot be derived.

Finally, this discussion is further complicated by the fact that the publications, upon which the USPSTF based their conclusion, evaluated only cognitive assessment instruments designed to detect “dementia”, not the asymptomatic subjects contemplated by the notion of screening. Therefore, an evaluation of the benefits and harms of screening older adults for the full range of cognitive impairment, based on instruments that reliably detect only the most severely impaired, is neither comprehensive nor conclusive.

The bottom line, as emphasized in the accompanying editorials to the USPSTF recommendations published in JAMA, is that wide scale screening of asymptomatic populations over age 65 is not yet warranted by published evidence, but it certainly has strong theoretical appeal. 

The USPSTF’s conclusion of “insufficient evidence” should not be interpreted as a recommendation against screening, rather, it is a factual statement about the paucity of studies that have been published in this area. But it should be noted that Medicare mandates the “identification of cognitive impairment” during Welcome to Medicare exams. So when asking if we should screen older adults for cognitive impairment, at least one well-informed branch of government believes that the benefits outweigh the costs.

Did Pfizer "Hide" a Potential Treatment for Alzheimer's Disease?


Contributed by: Dennis Fortier, President, Medical Care Corporation _______________________________________________
Despite the provocative title, this post is largely a summary of a non-story. However, it is worth discussing because this "non-story" has been widely covered in the general media, often in a manner that leans strongly toward the sensational end of the news spectrum.

The facts are fairly non-controversial. Pfizer, a major pharmaceutical drug developer and marketer, performed an analysis of medical insurance data comprised of approximately 254,000 patients with rheumatoid arthritis or another inflammatory disease. The analysis revealed that, among those patients whose inflammatory disease was being treated with Enbrel, a drug marketed by Pfizer in the US, a slightly smaller percentage also had an Alzheimer's diagnosis compared to those who were not treated with Enbrel. Despite the seeming potential for Enbrel to prevent Alzheiemr's disease, Pfizer conducted further internal review and opted not to initiate a clinical trial for the purpose of measuring the efficacy of Enbrel in preventing Alzheimer's disease.

As far as I can tell, no one is disputing those facts. However, how those facts are interpreted has become a matter of creative reporting. One angle that has created a fair amount of reporting (initially in the Washington Post) suggests that, because Enbrel is nearly off patent, after which the drug will be far less profitable, Pfizer made a greedy decision and opted not to pursue a potentially promising Alzheimer's treatment. Most drug development experts disagree with that suggestion.

The noted statistical evidence of a preventative effect of Enbrel against Alzheimer's disease was far smaller than what the drug development industry would generally require before initiating a trial. Furthermore, the effects of anti-inflammatory drugs in the Alzheimer's space have been thoroughly investigated in other studies to no avail. Given that Enbrel does not cross the blood-brain barrier, it is fairly unlikely that a long and expensive trial (see previous summary here of FDA drug approval process) would yield a favorable outcome. In fact, another major marketer of pharmaceutical drugs (Amgen), who holds the rights to Enbrel outside of the US,  reviewed the same data and also concluded that further investigation was not warranted.

Overall, small statistical patterns are commonly present in large data sets like the one discussed here. However, such patterns are not necessarily indicative of an underlying treatment with a clinically meaningful effect. In the opinion of most knowledgeable scientists (as summarized here by Derek Lowe), Pfizer made a prudent decision not to further evaluate Enbrel as a potential treatment for Alzheimer's disease.

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A better understanding and more awareness of Alzheimer's related issues can impact personal health decisions and generate significant impact across a population of aging individuals. Please use the share button below to spread this educational message as widely as possible. ____________________________________________________________