In mid-May, the American Parkinson Disease Association’s (APDA) Northwest chapter hosted a webinar on dementia, cognition and Parkinson’s disease (PD) with cognitive neurologist Dr. Nancy Isenberg.  Around 30% of PD patients will experience some cognitive challenges.  Dr. Isenberg mentioned 8 habits to help with cognition:  stress management, gratitude, good diet, exercise, sleep, cognitive engagement, connection, and support/care. 

For more information on cognition, please see the Stanford Parkinson Community Outreach webpage here.

For a recording of this webinar, please see the APDA Northwest YouTube webpage here:

Please see below for notes on the May 14th webinar.

Regards, 

– Joëlle Kuehn

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“Dementia, Cognition & PD” – Webinar notes

Speaker: Nancy Isenberg, MD, Center for Healthy Aging, Swedish Neuroscience Institute, Seattle 

Webinar Host: APDA Northwest

Webinar Date:  May 14, 2021 

Summary by Joëlle Kuehn, Stanford Parkinson’s Community Outreach

Introduction:

• PD is 2nd most common neurodegenerative disease (after Alzheimer’s)
• Global prevalence: 6 million
• 2.5x increase over past 30 years
• Protein implicated in neuropathogenesis of PD is alpha synuclein – synucleinopathy
• Strong genetic factors; otherwise it’s idiopathic
• Some risk factors such as head injuries, age
• Men  / women ratio is 3 / 2
• There are many subtypes of PD, which mandates a personalized approach

PD is more than a movement disorder:

• Motor symptoms: Bradykinesia, rest tremor, rigidity, changes in posture and gait
• Hyposmia, sleep disorder, sleep apnea, restless leg, rapid eye movement sleep behavior disorder (RBD), mild cognitive impairment to dementia, pain 

Cognitive decline in PD:

• Around 30% will experience some cognitive challenges with PD
• Heterogeneous mechanisms that cause this to occur (Lewy body pathology, as well as beta-amyloidopathy)
• No disease modifying therapies for the spectrum of cognitive issues in PD disease
• Genetic factors interact with physical activity (environmental and behavioral factors) and change outcomes in aging

PD cognition spectrum:

• Pre-mild cognitive impairment (MCI): 
  • Trouble multitasking, trouble staying organized, dysfluency 
  • Ideal time to intervene (no tested or available therapies)
• PD – MCI
  • No proven therapies
  • Functioning well in the world but may have these cognitive issues
• PD – dementia
  • FDA approved treatment: rivastigmine (cholinesterase inhibitor)

Many medications that can be harmful to cognition:

• Tylenol PM – Benadryl
• Anticholinergics
• Tricyclic antidepressants
• First generation antihistamines
• Antipsychotics
• Opioids
• Benzodiazepines

Risk factors:

• Early life: poor education is a risk factor
• Mid life: hypertension, heavy alcohol use, obesity, traumatic brain injury, poort hearing
• Later life: smoking, untreated depression, social isolation, physical inactivity, air pollution, diabetes

Single greatest risk factor for Alzheimer’s disease is age.

Rethinking memory loss:

• Is it an inevitable consequence of aging?
• Destigmatizing memory loss
• Think of it in the framework of chronic comorbidities (chronic disease model)
• Primary / secondary prevention
• Rehabilitation / prehabilitation
• Effective treatments
• How to best support and address symptoms – what are symptoms that need targeting
• How can we bolster with retained strength

Importance of lifestyle:

• Extremely important and takes practice
• Consistency of the behaviors are what provides the momentum/traction in physiology 
• Practices take practice
• Combining multiple healthy lifestyle factors may be more impactful for reducing dementia risk
  • Healthy diet
  • Moderate to vigorous physical activity
  • Light to moderate alcohol intake
  • No smoking
  • Cognitive stimulation
• If you do 4 or 5 of these, 59% lower risk of Alzheimer’s dementia
• If you do 2 or 3 of these, 39% lower risk
• Following this lifestyle may even offset risk associated with genetics

Components to staying well:

• Treatment of modifiable risk factors:
  • Cardiovascular
  • Sedentary lifestyle
  • Sleep disorders/disruptions
  • Mood
  • Alcohol
• Medications – optimizing polypharmacy
• Exercise
• Cognitive activation and rehabilitation 
• Dietary intervention 
• Meditation / mindfulness-based stress reduction
• Community engagement and socialization

Good habits:

• Stress Management
  • Mindset medicine
  • Mind body practices 
  • Benefits of deep breathing:  Increases attention, focus, endorphins
  • Mindfulness meditation improves cognition:  Meditation slowed the rate of hippocampus volume atrophy in those with MCI when compared to randomized control group
• Gratitude, Awe
  • Daily affirmations
  • Sometimes we need to be told we are capable of everything in order to get through our day
  • We can use daily affirmations as an anchor to help us regain our focus, cultivated confidence, self-acceptance from within
• Diet: 
  • Heart disease mortality is increasing, driven by diet, exercise and lifestyle choices, mediated by an increase in obesity and type II diabetes mellitus
  • Plant based diets are associated with lower rates of obesity and diabetes, high quality of life and longer life-expectancy, as well as hypertension, dyslipidemia, peripheral artery disease, coronary disease, myocardial infarction, erectile dysfunction, heart failure, stroke and death
  • In our dual pandemic we need to advocate for risk factor reduction, whenever and wherever possible, to reduce mortality associated with nutrition-related mortality
  • Mediterranean diet is best 
• Exercise
  • Walking for 3 hours per week for 3 months causes so many new neurons to grow that it increased hippocampal volume
  • Exercise increases size of hippocampus and improves memory
  • Doesn’t have to just be walking, can be boxing, biking, etc.
• Sleep
  • First 4 hours- physical repair and memory
  • Next 4: emotional clearing, problem solving 
  • On average, we need 7-8 hours of sleep
  • What good sleep gives us:
    • Promotes cell regeneration
    • Consolidates memories
    • Reorganize information and solve problems
    • Process emotions
    • Enhances performance
  • Sleeping too little in middle age may increase dementia risk 
  • Tips for sleep:
    • Stick to schedule and avoid long (more than 40 min) naps
    • Don’t be a night owl
    • Wake up early to morning light
    • Get moving
    • Watch what you eat and drink (no caffeine after 2).  Limit food and drink 3 hours before bed
    • Mind your meds including OTCs 
    • Cool, quiet, dark
    • Eliminate electronics
    • Bedtime ritual
    • Know warning signs and seek help for snoring and insomnia
  • Function of sleep:
    • Restore: cool brain and body
    • Reset: regulatie ion channels
    • Repair: optimize physiological growth
    • Anti-inflammatory: Reduce inflammatory markers
    • Heart health: Actively cardio-protective
    • Brain health: enhances neuroplasticity
    • Memory: improve memory formation and consolidation
    • Improve mood: soothe emotions and mental fatigue
    • Joy: connects us physically, mentallly, and emotionally
    • Energy: replete energy stores
• Cognitive engagement:
  • Becomes harder with covid 
  • What can increase risk for cognitive decline?  Traumatic brain injury, mid-life obesity, mid-life hypertension, current smoking, diabetes, history of depression, sleep disturbances, hyperlipidemia
  • What decreases risk for cognitive decline?  Years of formal education, physical activity, mediterranean diet, cognitive training, moderate alcohol consumption, social engagement
• Connection
  • Isolation and depression leads to chronic stress and heart disease
  • People suffering from loneliness, depression and isolation have 3 to 10 times greater risk for premature death 
  • Intimacy is healing
    • You can only be intimate to the degree that you can be emotionally vulnerable, and you can only be vulnerable to the degree that you feel safe
    • Group support is a safe environment for you
    • Love is medicine
• Support / care
  • Partner with a team where you feel seen/heard
  • Adjust medications with doctor in a way that is most effective to you
  • Information is not sufficient to motivate most people to make sustainable lifestyle changes 

Question & Answer: 

Question: Can you say a bit more about mnemonic scaffolding?

Answer: It’s a memory strategy. We’re able to develop support strategies so we can optimize brain function. It’s like having a landing pad where we put our keys or phone. It’s to help you remember better.

Question: Is there a comprehensive evaluation of some of the areas that were discussed available for someone with PD?

Answer: Absolutely. You should see a neuropsychologist or a cognitive neurologist and they can work on some of those with you. You can also go to an occupational or speech therapist for practical and creative skills and assessments. 

Question: How do you know if you have APOE4?

Answer: It’s a blood test.

Question: Does the sleep you get need to be continual, like 7-8 hours, or can it be cumulative throughout the day?

Answer: Ideally you’ll get most of it at night. Some people do have fragmented sleep, so it doesn’t work for them. If you had a bad night’s sleep you may need a nap, but the problem is that if you start napping a long time during the day, you’re going to disrupt your circadian rhythm.  it tells you to be awake during the light and be asleep at night, you don’t want it to get out of alignment. A 10 or 15 minute nap can be an incredible way to regain strength and energy.  

Question: For someone who has mild cognitive impairment with delusional thoughts, how can a long-distance care partner help and engage with someone like that?

Answer: If someone is delusional, let their medical team know to make sure something else isn’t going on. If it’s in the context of anxiety or depression there are different things to try, but without an assessment it’s hard to say. Often people are delusional if they are afraid, so getting more support and psycho-education around a team-based support network in the home. First clarify what’s happening and then work to bring in more support and resources.

Question: How important is it to pin down the accuracy of a diagnosis (dementia, Lewy body dementia)?

Answer: Some medications aren’t approved for both forms of dementia. Some people say that they’re really different, some people say it’s a spectrum with certain diagnostic criteria of Lewy bodies. What’s important from the perspective of patient-centered care, is to have a conversation with a doctor and discuss symptoms and have an exam. 

Question: My wife has cognitive difficulties and stares and freezes, should I get her assessed for memory problems?

Answer: A medical exam can help to diagnose what is going on.

Question: Tips for restless legs as it impacts sleep?

Answer: Restless leg syndrome can really impact sleep. It’s a common sleep disorder in PD. Before treating with medication, I would make sure you’ve had your ferritin tested and don’t have an iron issue and have done stretches. Taking magnesium for cramping can be helpful. Make sure you bring up all the medications you are on to your doctor. Start tracking it, keep a diary. 

Question: Is there a way to mentally control freezing?

Answer: It’s such a challenge in PD. It’s a really hard symptom. I’d track it and find out when it’s occurring in relation to your medicine. It could be when the medication is wearing off. Work closely with your team and a physical therapist.