Playing Professional Football, Concussion, and Cognitive Impairment Come Together

Yesterday (August 30, 2019) The Journal of American Sports Medicine published the results of research on the history of concussion and cognitive changes in NFL players.  In this magazine article, the authors interviewed the investigators.  The study found that the longer a player's career, the greater the risk he would develop cognitive problems.   It did not address Alzheimer's disease or dementia, but we discussed how these might be related to traumatic brain injury in Beating the Dementia Monster.  We will dig deeper into the subject in the second edition.

The study was conducted at the T.H. Chan School of Public Health (formerly the Harvard School of Public Health).  The investigation was conducted primarily by querying 13,720 NFL players, past and current, of which 3,506 responded.  A questionnaire asked players to self-report on ten symptoms, mostly focused on anxiety and depression.  From this the researchers determined a cognitively-related quality of life score.

The researchers found that the number of NFL seasons of play and playing position were associated with lasting neuropsychiatric health deficits.  They also found that poor cognition-related quality of life, depression, and anxiety seemed to be associated with concussion over time.  Twelve percent of players reported cognitive problems vs. two percent in the general population.  Players who played ten seasons or more were twice as likely to report problems.

While I don't doubt the findings, it occurs to me that there may be some skewing of their data.  If so, this possibility wasn't addressed in the abstract.  (Wasn't willing to pay $40 to get the whole article...)  The researchers sent the questionnaire to a substantial population of players, but only got back a quarter of them.  I wonder if the severity of symptoms might have either dissuaded players or encouraged them to return their surveys.  If so, the investigators' sample may not have been representative of the whole population of subjects.  Also, NFL players live a different lifestyle than most of the rest of us, so there could be other drivers for anxiety and depression.

Again, they did not (at least in the study abstract) relate their findings to Alzheimer's disease or dementia.  However, there is plenty of other research making that connection.  Something to bear in mind is that Alzheimer's disease begins a decade or two before the symptoms appear, so the worst may be yet to come for some of these players. 

The Alzheimer's Project Documentary

I have just finished watching about 5 hours of the video series, The Alzheimer's Project.  It was from HBO, and it was produced by Maria Shriver among others.  It was produced in 2009, so the information was a bit dated.  Nevertheless, it was worth my time.

Some of us may remember when President Kennedy appointed his brother-in-law, Sargent Shriver, to found the Peace Corps.  His later struggle with AD prompted his daughter Maria to be an advocate for Alzheimer's research.  She wrote a children's book, What's Happening to Grandpa to help children understand AD.  She later produced a movie for children with the same theme.  And The Alzheimer's Project earned Maria a couple of Emmy Awards.

Did I say 5 hours?  But I still have the third DVD to watch!

The DVDs were loaned to me by a friend who participated in brain research a few years ago.  (But now she's a lawyer.)

The first DVD was a series of vignettes about some AD sufferers' and their families.  It was very moving.

The second DVD was about where we stand in the search for a cure.  Or, rather, where we stood in the search for a cure in 2009.  What was sad in this segment was the level of optimism that existed at that time regarding how close we seemed to be.  But so many of the ideas they were pursuing then have since turned out to be dead ends.

They introduced Dr. Carl W. Cotman, who is credited with discovering the power of the brain-derived neurotrophic factor (BDNF) to heal damaged brain cells and to prompt the formation of new brain cells.  We describe this in Beating the Dementia Monster.  He discussed the power of aerobic exercise to generate BDNF and beat back the advance of AD.  This promise is, at least, is being fulfilled today, at least to the extent that we're willing to get out there and get that exercise! 

Looking for Anecdotes

My book editor friend reviewed the manuscript for the second edition of Beating the Dementia Monster, and he gave me an excellent suggestion.  He said that I should find other people with an experience similar to mine and include brief anecdotes about them in text boxes.  Probably a single paragraph.  This is done pretty often, and it's a great idea for the new book.

So far, I've found one person.  She's a lawyer living in Western Washington who has been dealing with younger-onset AD for ten years.  She's about two years younger than I am.  She says she is having more problems lately with her short term memory, but she's still able to live independently.  And she checks all the boxes for a brain-healthy lifestyle: walks at least a mile every day, eats a Mediterranean diet, participates in the constant social activities in her senior living facility (includes dancing), and sleeps well.  She says her most important asset is that she has a very positive attitude.

She has a point about the positive attitude -- which is consistent with recent research.  Some of the hormones and proteins present during depression attack the hippocampus and aggravate AD.

If you know someone else with a story who would be willing allow me to write to them, please let me know: dave@dave-b.net.
   

The Evidence Keeps Rolling In

Some important new studies were reported at the Alzheimer's Association International Conference in April in Los Angeles.  The studies were about the effect of lifestyle changes on prevention and treatment of AD.  This, of course, is what Beating the Dementia Monster is all about.

The first study was conducted by Dr. Klodian Dhana of Rush University.  It looked at five healthy-lifestyle factors: diet, exercising at least 150 minutes a week, smoking abstinence, limiting alcohol intake, and engaging in cognitively stimulating activities.  The cognitively stimulating activities included reading newspapers, playing cards, or visiting libraries and museums.  The study examined how these reduced Alzheimer's risk.  There were about 2,500 subjects who were followed over a ten year period.

Subjects who adhered to at least four of these healthy habits had a 60 percent decrease in risk of developing AD, and even those who had two or three of them had a 37 percent decrease in risk, compared with those who engaged in one or none.  That's pretty powerful!

Another study from the UK tracked the genetics, lifestyles and Alzheimer's disease incidence of nearly 200,000 British people over 60 for an average of eight years.  The study was led by Dr. David Llewellyn at the University of Exeter Medical School.  What did it find?  Among people found to be at highest genetic risk, healthy living appeared to reduce the chances of developing the disease by 35 percent.  According to the researchers, that implies that 1 case of dementia would be prevented for each 121 individuals every 10 years with high genetic risk who improved their lifestyle from unfavorable to favorable.

All of this, of course, underscores everything we've been saying here and in Beating the Dementia Monster.  I hope to strengthen the case in the next edition.

Beating the Dementia Monster, Take 2

We published Beating the Dementia Monster in February 2018.  If you read this blog, you know that a lot has happened since then.  And I've been acutely aware of some significant shortcomings in the book.  Aside from leaving the reader hanging about the insulin trial, the appendix always seemed a little amateurish to me.  I have felt for a long time that a new, better edition was in order, and I can do it.

So I've been working on that.  I have a new manuscript, and it is being reviewed by several authorities.  Both the doctor and the neuropsychologist that reviewed the first edition have reviewed the manuscript.  Also, a friend of mine from high school who retired from the book publishing industry has been hugely helpful, as has someone senior from the Alzheimer's Association.  I'm also hoping to get a neurologist.  I'll identify people by name in the acknowledgements section of the book.  (My nephew Gavin who is a published author and works for a publishing house offered to help as well.  I may yet go to him.)

This time, I want to have it published traditionally rather than the self-publishing route I followed before.  The first edition is still selling well on Amazon, and I got another 5 star review the other day.  But I can write something better, and I have.

Getting a book published traditionally turns out to be pretty challenging.  It seems that publishers don't want to accept manuscripts from authors, they need to be filtered for them by an agent.  So I need a literary agent.  That turns out to be its own challenge with highly specialized protocols. 

My classmate helped me craft a query letter.  That's pretty straightforward -- tell the prospective agent why your book is so great in one page, maybe a page and a half.  But he suggested a lot of things that never occurred to me.  Oh, you also need to explain how you plan to promote the book, since publishers don't do that anymore.  You are the publicist, and you need to convince the agent that you have the wherewithal to do that..

The agent also needs to see a book proposal.  This is a business plan for the book that analyzes the market and describes how the book will be generated and sold.  It's a minimum of ten pages, but maybe 50.

I need to start writing the proposal now, but I hope to get some reviews and endorsements before I actually begin approaching agents.  I also want to get at least one more speaking gig under my belt.  That will be on September 22.  Then something for the Alzheimer's Association in the spring.

Scratching my head...

A study just published in Alzheimer's and Dementia looked interesting, but it left me a little puzzled.  The study, "Assessing cost-effectiveness of early intervention in Alzheimer's disease: An open-source modeling framework," described development of a framework for assessing cost-benefit for as yet unknown future treatments of AD.

This year's Alzheimer's Association Facts and Figures Report marveled at the tsunami of cost that AD will inflict on the US in coming decades, and spoke to how much can be saved if AD is identified and treated early -- either in the MCI stage or even the pre-clinical stage.  The problem is, there are no effective treatments of the type considered -- drug or other therapy.  Also, when such a treatment arrives (assuming it does), how much will it cost in relation to what benefit it will provide?  The study considered the cost to individual families as well as the cost to society in general.  The study reported on development of an approach to assessing this.

One thing that struck me about the article was what seemed to be a badly outdated understanding of where the search for this therapy stands.  It acknowledged the painful journey to such a drug or other intervention, but then cited old research positing the possibility that the human monoclonal antibody treatment Aducanumab might finally be that therapy.  Huh?

Their references about hope for Aducanumab were old, from before the last round of trials were abandoned.  We discussed this in March.  Perhaps they're holding onto the possibility that applying the therapy in the pre-clinical stage might produce better results.  But there seem to me to be more doubters than believers on that.  The study did talk to treatments that address AD in the pre-clinical and MCI stages.  In fact, it modeled disease progression through the three recognized stages of the disease -- pre-clinical, MCI, and Alzheimer's dementia.

My sense is that people anticipate that an effective treatment for the pre-clinical and MCI stages of AD will be unlikely to bring someone back who has advanced into Alzheimer's dementia.  

My takeaway from the study is that this is a tool that will be on the shelf until the day we have an effective, but likely expensive treatment.  At that point, when many unknowns have been clarified, it can be used to determine how to ration the treatment -- at what point is spending more money not returning a benefit.   

Earhquakes and Dementia

In Beating the Dementia Monster, we emphasized the importance of maintaining social connectivity in confronting Alzheimer's disease.  Somehow, social activity provides a preventative and healing function for AD.  It's likely beneficial for other causes of dementia as well.

There is now a six-year longitudinal study of victims of the 2011 Great East Japan earthquake and tsunami.  The results were reported in Alzheimer's and Dementia: the journal of the Alzheimer's Association.

The study found a correlation between loss of housing and development of "cognitive disability," which looks to me like development of dementia.  This continued after six years.

My first assumption when I saw the headline was the people who lost their homes also lost family, friends, and other sources of social support.  This promotes the advance of AD.  The authors of the study came to a similar conclusion.  The authors also proposed that promoting civic participation may improve cognitive resilience.

      

Dr. Dale Bredesen Interviewed

Today, I watched a YouTube interview with Dr. Dale Bredesen, author of The End of Alzheimer's, conducted by Dr. Joseph Mercola.  Mercola is an alternative medicine vlogger, and the interview was posted on July 28.  Both men are controversial, but I got answers to a couple of questions I had.

I discuss Dr. Bredesen's work in Beating the Dementia Monster, noting that the core of his protocol for addressing AD are the things that continue to work for me.  However, he adds many, sometimes expensive tests and dietary supplements which have not been shown scientifically to improve cognition.  I have met brain health professionals who are really frustrated when people come in asking for the expensive tests of doubtful utility that Bredesen recommends.

Having heard this, I have wondered just how expensive the tests really are.  During the interview, Mercola said he estimated the tests to cost around $10,000.  Bredesen didn't dispute this number, but he said that his most basic tests could be done for about $1,000.  But the insurance companies won't pay for them.

Bredesen's initial research that led to development of his protocol involved only a handful of test subjects.  In his book, he documented a few more.  Now that he has licensed a number of clinics to implement his protocol, he says that he now has over 100 anecdotal success stories. 

I read The End of Alzheimer's, and in it Bredesen discussed the problems he has experienced in getting respect for his protocol from the research and academic community.  He believes the problem is that they all think in terms of a single silver bullet, but his protocol takes a systems approach requiring many factors to work together.  So he has not been able to get approval for a study that would be a candidate for a peer-reviewed journal.  In the book he said he believed that he would eventually receive the approval he needs, and in the interview he gave details about the genesis of a new study, naming the investigators.  So we will see.

At this point, my critique of Bredesen is that the success story anecdotes from his research and in his book all begin with the core domains we discuss in Beating the Dementia Monster.  He needs to prove that adding the expensive stuff will improve results.

They discussed something else that concerns me.  That is the potential for the explosion in the use of cell phones to, over time, create possibly catastrophic changes in brain chemistry.  On the one hand, the wavelength of microwaves from the phone are such that they are not expected to interact with atomic and subatomic particles in a way that might change them.  They should not cause electrons to change their energy levels or cause atoms to be ionized and thus not cause chemical reactions.  On the other hand, the inverse square law tells us that a fair amount of energy will pass through our brains when the phone is held up to our heads, and I suspect intuitively that it must have some consequence.  During the interview, they discussed some possible ways that microwaves could cause changes that could lead to AD.  But they acknowledged that these are speculative.