Post Script

During my June 22 visit with my neurologist, she said one more thing worth mentioning.  She said that, while the practice effect can inflate test scores, they still look at it as a positive indicator.  For the practice effect to have influenced test performance, your brain must have successfully encoded the memories. 

It just keeps getting better

On June 11 we traveled to Harborview in Seattle for my annual cognitive testing—almost four hours worth. I was anxious because I had slept very poorly the night before, and I had foolishly scheduled the testing for the afternoon. I’m a morning person, and when I’ve missed sleep it might not hit me until the afternoon. But, we went ahead with the tests, and I was surprised at how well I felt about how I’d done.

Not being a patient person, I wanted to know the results immediately. But they needed to be analyzed and assessed before the doctors could share them with me. So I needed to wait; we would need to return more than a week later to hear the results.

Before the test began, I had a discussion with the new neuropsychologist who will be following my case. We discussed the status of the SNIFF (insulin) study, and the fact that I had been getting quarterly psychometric testing from them. I wondered about how “the practice effect” might influence my results. She said that was a consideration, and she had made some changes to the test suite to differentiate these tests from what I had taken before.

Yesterday (June 23) we made the trip back over the mountains to meet with my neurologist and review the results. They were even better than I had anticipated.

It was true that the neuropsychologist had shaken up the test suite, and so I can’t make the sort of year-over-year, test-by-test comparisons that I’ve made before. Nevertheless, there were 42 individual assessments, and I could easily get an overall sense for how things were compared to 2015 through 2017. In 23 tests I scored high average, superior, or very superior. As I write this, I’m still in Seattle, and I don’t have my old tests available. But I don’t recall ever having received a “very superior” before. There was only one low average, and none of the below average scores that I had sometimes scored in the past.

In her summary assessment, the neuropsychologist identified five areas in which I had improved (single-trial learning and delayed recall from a word list, both semantic and phonemic verbal fluency, basic attention, and visual tracking/psychomotor speed), adding that some of them may have been inflated due to the practice effect. But from a broad cognitive standpoint, she wrote, “Mr. Brown is doing very well across all domains.”

My neurologist was quite enthusiastic about the results, and agreed that the improvements were likely a consequence of the lifestyle changes I’ve made. She mentioned that at least one other professional in her office had gotten a copy of Beating the Dementia Monster.

During the visit, we reviewed images from my most recent MRI (February) and compared it to the MRIs of 2012, 2015, and 2017. Some of these were done using the research machine for the SNIFF study. What we specifically looked for was a way of understanding the assessments of hippocampus volume. (The 2015 radiologist report had me in the 36 percentile of people my age, but the SNIFF study reports had me at less than the 1 percentile.) She didn’t try to assign numeric values from the images, but it was evident that there was little or no deterioration from the time I made the lifestyle changes I describe in Beating the Dementia Monster (December 2015). Nevertheless, there were notable changes (atrophy) between the 2012 images and the 2018 images.

So how do these results affect my future course? The neurologist said that we should not do cognitive testing next year. I will have a closeout suite for the SNIFF study in August, but I should take a break from cognitive testing after that until the summer of 2020. She said I should return next summer for an annual visit to see how things are going. We’ll be alert for anything unusual or unexpected, especially when the SNIFF study ends, and I’m taken off the insulin.

I won’t lie. Some mornings it’s really hard to get on that treadmill and keep it going for 45 minutes. But it’s really worth it.

Another one bites the dust

This week's ALZForum carries the story of another Alzheimer's disease drug trial that was terminated early.  The drug is Lanabecestat, which is a "BACE inhibitor."  The concept behind BACE inhibitors is that they can inhibit the generation of an enzyme that is specified in the BACE1 gene.  The enzyme cuts the "amyloid precursor protein (APP)," and a fragment from the cutting process is beta amyloid.  In AD, the amyloids accumulate on the neurons in the brain and interfere with their function.

What is the purpose of APP? No one knows.  Why does the BACE1 enzyme cut APP molecules?  No one knows.  But suppression of the BACE1 enzyme suggests logically that it could help control AD.

Several BACE inhibitors have been tried, but drug trials have been terminated prematurely because of bad side effects (e.g., liver damage), or they just weren't working.

This is just one more discouragement in a long string of discouragements in AD research.  When I was first diagnosed in 2015, the buzz I was hearing in the science media was that we would have an effective AD drug to market by 2019.  How things have changed.

At this point in time all we have for treating AD is what I explain in Beating the Dementia Monster:

• Get daily aerobic exercise (45 minutes a day, 6 days/week)
• Eat a Mediterranean or similar low-carbohydrate diet that favors leafy green vegetables, fish and poultry, and blueberries and strawberries
• Maintain social activity
• Get good, regular sleep
• Reduce stress (e.g., do Yoga)

The Alzheimer's Progression

We discussed earlier that the term Alzheimer's disease is now applied to the entire progression of the disease, not just the Alzheimer's dementia stage.  This has caused confusion among some people I've spoken with because we have always thought of Alzheimer's disease as simply dementia.  But the disease may actually begin a decade or more before the first symptoms appear (we don't really know).  The first symptoms produce the condition we call MCI. 

Each case is different, but a person with AD will often be considered to be in the MCI stage for about five years.  This, of course, assumes there is no intervention.  We contend that lifestyle interventions, such as exercise and diet, will delay the progression to Alzheimer's dementia by as much as 10 years.  That's a long time.

(There are other diseases and issues that can produce MCI.  MCI identifies a broad category diseases and disorders; AD is just one.)

I have prepared this graphic to help explain the progress of AD.

 

Ghost Blood Vessels -- Correction

In my post of June 30, I said the Ghost Blood Vessels video said that the calf is the biggest muscle in the body, but my brother wrote me and challenged that.   So I went back and watched the video again to see what they actually said.  What they actually said was that we think of the heart as the most important mover of blood, but the calves also play an important role in blood circulation.   They didn’t say anything about how big the calf muscle is.  Ooops.

Remember from your middle school biology that, while the heart pushes blood through the circulatory system, flow is very much assisted by the flexing of muscles.  Blood vessels are designed such that blood can only move in one direction, so that each muscle can serve as a sort of booster pump.  Flexing muscles squeeze the blood vessels and force the movement of blood, but it can only move one way--the direction the heart is working to push it.  This is why we stretch when our body wants to increase blood flow.

Ghost Blood Vessels

My brother-in-law watches a lot of television from Japan, and he just sent me a link to this very interesting video.   I’m not sure how well founded all of their claims are, but I think the video provides some insights.

The video is about “ghost blood vessels,” which are capillaries that atrophy with old age.  They’re referred to as “ghosts” when they no longer can carry blood.   They say that capillaries in the skin atrophy, so that the skin wrinkles and sags.  Capillaries supplying blood to bone tissue atrophy, and there is osteoporosis.  Capillaries in the brain atrophy, and this can cause dementia.  They link this to Alzheimer’s disease, but in a way that I’ve never seen described before.  So I’m not confident in the factuality of some points, but there is logic.

The question is, how do you stop or reverse the formation of ghost capillaries?  The video explains that “pericytes” are cells that wrap around capillaries, and give the capillaries their shape.  They expand and contract to regulate blood flow, notably in the brain.   In aging blood vessels, they may be lost from the capillary, and the capillary loses both its shape and the ability to conduct blood flow.  This is how ghost blood capillaries are formed.

The video claims that carbohydrates in the blood stream damage the pericytes and cause them to be lost.   So they recommend restricting or eliminating carbohydrates from your diet.  The video also claims that vigorous aerobic exercise stops the formation of ghost capillaries, and the recommend daily exercise.  As we discuss in Beating the Dementia Monster, removing carbohydrate from your diet and getting vigorous aerobic exercise both combat AD, so there is a connection here. It also suggests how physical exercise fights osteoporosis, something I’ve always wondered about. 

As far as exercise goes, they recommend skipping.  The idea is that the calf muscle is the biggest muscle in the body, and exercising it promotes blood flow.  Skipping will promote blood flow more than any other activity.  Or so they say.

More good news

We were in Seattle this week for my latest quarterly cognitive testing for the insulin trial.  These were similar to the tests of last November … an hour or so of tests, but not as comprehensive as the biannual tests.  (I had comprehensive, biannual testing in February 2017, August 2017, and February 2018.  The study ends for me in August 2018 with one last comprehensive testing session.)

So what were the results?  Pretty much unchanged from November 2017 when I did extremely well. As in November, in the test using 10 words, I could remember nine of the ten at the end of the test.   In the 12 word test, I missed one word, when I had gotten a perfect score in November.   I don’t think that’s significant.

I did better on this testing than in February, but that was because I had stayed up too late the night before the February testing.  I did not perform well then.

Since I’ve been off the placebo and on the real insulin since February, the study coordinator asked me if I thought it was working.  I said no, I don’t think so.

So what’s next?  We head back to Seattle on Friday for my annual cognitive testing at Harborview. (My brain gets to rest for a week.)  This is entirely separate from the insulin trial, but the tests will be similar to the comprehensive cognitive tests for the insulin trial.  They’ll run several hours.  For me, the insulin trial will be over in August, but I expect to continue to receive annual care at Harborview for as many years as I can get there.