Dementia – Multiple Trials & Interventions to Delay Cognitive Decline

There have been multiple studies presented at scientific meetings recently that look at what influences the development of dementia and what may delay it. We have known for years that anything that interferes with sensory input to the brain can lead to increased risk of dementia. Improving hearing with hearing aids was found long ago to improve your chances to avoid dementia as you age.

A recent study published by Cecelia Lee, MD MS in JAMA Internal Medicine revealed that individuals undergoing improvement of vision with cataract surgery reduced their risk of dementia significantly. The study looked at over three thousand patients undergoing cataract surgery and or glaucoma treatment between the years 1994 and September 2018. Patients were evaluated every two years during the study with Cognitive Abilities Screening Instrument (CASI) and those with scores indicating a cognitive decline were referred for more detailed testing. Although having cataract surgery reduced your risk of dementia treating glaucoma, it did not provide the same risk reduction for dementia. There were numerous theories on why cataract repair helped based on the type and quality of light reaching the retina and brain, but it was an improvement to normal in another of our senses.

Another study looked at the effect of taking a daily multivitamin on the risk of developing dementia. This study funded in part by Centrum Silver and called the COSMOS trial looked at 2262 men and women all older than sixty-five with a mean age of seventy-three. They were evaluated before entry into the study with cognitive tests and again every year for three years. Those taking a multivitamin exhibited a “slowing of cognitive aging by 60%”. Taking a multivitamin seems like an easy inexpensive intervention to preserve cognitive function and hopefully these results will be confirmed and reproduced in future studies.

Recent studies looked at the benefits in maintaining brain volume and cognitive function when drinking coffee and tea containing caffeine. The studies showed that coffee drinkers benefitted more than tea drinkers but they both benefitted in reducing the risk of cognitive decline. A recent publication took the research a step further by having test subjects drink several cups of coffee and several cups of tea per day. The benefits of drinking both beverages on the same day were far greater than drinking individually.

    Last but not least , a study executed by the Cleveland Clinic Genomic Medicine Institute under the direction of F. Cheng, PhD, looked at insurance data to determine if taking Viagra (Sildenafil) modified your risk of developing Alzheimer’s disease (one form of dementia)  The study over a 6-year period suggested that Viagra users were 69% less likely to develop Alzheimer’s disease than non-Sildenafil users. This study, which was announced and covered extensively on television news and the print media, resulted in more phone calls to my office than the other studies. This was an observational type of study and further research is needed before prescribing this medication for this preventive reason.

Of interest to me was the fact that most of the men who called asking for Viagra after reading this article were on other medications for other medical illnesses that prevented them from safely using Sildenafil products.

Alcohol & Gastrointestinal Cancer

For many years now we have been taught that adult consumption of alcohol in moderation is an acceptable life practice. We have been told that women can safely drink one alcoholic beverage per day, if not pregnant, while men can drink two per day. Of course, driving a car or handling machinery while under the influence is not acceptable. We were also taught that our alcoholic beverages were highly caloric and that they, in fact, were considered “empty” calories providing little if any nutritional benefit.

Unfortunately, the purchase and consumption of alcoholic beverages during the COVID-19 Pandemic has markedly increased as a result of isolation, stress and quarantine.  We have also seen individuals binge drink large quantities of alcohol and even seen individuals become toxic with alcohol poisoning. Moderation and being responsible are always stressed with regard to alcohol consumption.

A study in JAMA Network Open may make us reconsider those ideas. This study looked at the adult South Korean population from 2009- 2017 who did not have a gastrointestinal cancer diagnosed. They followed almost 12,000 adults aged 40 or older with 40% agreeing they drank alcohol. Participants were divided into mild, moderate and heavy drinkers based on the volume of alcohol consumed. They were then followed and compared to the non-drinking portion of the group for the development of GI cancers.

The study found that the frequency of drinking is more of a risk factor for developing GI cancers than the actual volume consumed. In fact, among mild drinkers, those who had an alcoholic drink 3-4 nights a week had a greater chance of developing a GI cancer than those who drank heavily but less frequently.

In life nothing comes without a price. The question I raised and have not received an answer to is “Just how high is this risk?” Is the risk of developing a GI cancer with a cocktail with dinner equivalent to the risk of being killed in an auto accident on a major highway? Is a cocktail with dinner riskier than smoking a pack of cigarettes per day, or sky diving?

Until someone can present the data in a manner that I understand the true risk, it’s difficult to develop a health recommendation. Were these results an outlier unique to the Korean population? When I know based on evidence, I will let you know. Until then “cheers.”

Should I Measure My COVID Antibodies?

On a daily basis I get asked by patients to please add an antibody test to their necessary blood work monitoring chronic conditions and medications to see if they have immunity against COVID-19. Some want the information just to feel comfortable that they have responded to their vaccine administration. Some have had COVID-19 and want to see if their immunity is sufficient to avoid taking a COVID-19 vaccine or booster shot? Some who have not been vaccinated and have been ill recently but not tested just want to know if the illness was COVID-19.

The topic was just reviewed in the online journal MedPage Today. First of all, the test you order to determine if you developed immunity based on receiving the vaccine is different than the test you order to measure antibodies arising from a previous infection. Nathan Landau, PhD, a virologist with the NYU Grossman School of Medicine believes we do not yet have the data to determine if antibodies we develop from infection or vaccination are appropriate to provide immunity. “The real answer is we just don’t know. It takes time to gather that data, to know what titers people have and what their chance of getting infected is.”

To determine the level of antibody that is needed to prevent infection scientists must first perform neutralization assays or tests. These are not performed in the commercial labs that do antibody tests for COVID-19. The neutralization assay is the Gold Standard . The test is performed by taking the blood of an infected individual, isolating the blood serum and then diluting it into different strengths. The different strengths are then mixed with the live Sars2 Coronavirus in a set amount. They then observe if the virus is killed off.

 In order to kill the virus you must have neutralizing antibodies. The commercial labs only measure the total antibody not specifying how much of that is actually successful in neutralizing the live virus. The neutralization assay looks to see what dilution of the antibody kills off 50% of the virus.

For example a dilution of 1:100 means 1 milliliter of serum was mixed with 99 milliliter of saline. At this point we do not know what dilution is necessary to prevent infection. This data is known for diseases such as measles, German measles and different strains of hepatitis.

There has just not been enough time yet to make this determination but the research is ongoing and conclusions should be released soon. What is known is that the mRNA vaccines produce more immunity than the non mRNA vaccines. They also know that the antibody produced from a vaccine is superior to the immunity from infection against new variants and reinfection. The commercial tests are expensive, time consuming and use reagents affected by supply chain problems.

Zinc For Colds This Season?

Two weeks ago, my wife was doing her weekly childcare activity of love watching our two toddler grandchildren while our adult kids were on a business trip. The 3.5-year-old had brought home a viral respiratory infection the week before, gave it to his one-year-old brother and both kids were now in the tail stages of recovering from annoying but not serious illnesses.

In today’s world, coming home from school with a sore throat, runny nose and malaise means tea and honey, warm soup and a COVID-19 test. Both kids were negative but several days later my wife, then I, had similar symptoms. My wife’s symptoms settled in her sinuses and 10 days later her doctor put her on antibiotics and nasal spray. I was fortunately much less symptomatic but still have some nasal congestion and dry cough. We have a commercial preparation of a zinc product to prevent and reduce the symptoms of these infections but did not get around to taking them. In the past the literature wanted us to take these lozenges every two hours and I was not going to set an alarm at night to wake up to suck on a zinc tablet.

Jennifer-Hunter, PhD, from the Western Sydney University and associates studied the questions about zinc products’ effect on preventing and abating the common cold and published their findings in the online version of the BMJ Open on November 1, 2021. They looked at 28 randomized controlled studies with 5,456 patients. Their results showed that oral or intranasal zinc did prevent about 5 infections of those exposed per 100 persons when compared to a placebo. They found that if you challenged healthy individuals with a human rhinovirus inoculation the sublingual zinc did not prevent a clinical cold. Those who continued the zinc tended to have resolution of symptoms two days earlier than those who took placebo. For those who took the zinc prep there were more episodes of nausea and mouth and nose irritation.

I appreciate the science and think I will pass on the zinc for now and stick with avoidance of sick individuals plus chicken soup, tea and honey when I catch the virus anyway.

Exercising With a Mask is Safe

My daughter was trying to come to terms regarding what to do about school with our 3.5year old grandson. Her friends were applying peer pressure to send him to school citing permanent psychological and developmental damage from staying isolated at home. She signed him up for a school that does not have a vaccine mandate for teachers and staff but does require that the children wear a mask indoors and in close contact situations outside. “Don’t you know that masks are unhealthy for children. They have to breathe more carbon dioxide.” said another mom. 

Rising carbon dioxide levels produce a reaction to breathe, which is a good thing. So, I searched the literature to find something that provides evidence that masks are safe.

Matthew Kampert, D.O. and colleagues from the Cleveland Clinic performed exercise stress tests on active young men wearing no mask, wearing a N95 mask and wearing a cloth mask with a charcoal filter. Their results were published as a letter in one of JAMA’s online forums.

These men each exercised until they were exhausted in three scenarios. Without a mask they exercised for a mean duration of 591 seconds versus 548 seconds with a cloth mask and 545 seconds with an N95 mask. They all felt that breathing resistance and humidity was higher with either mask.

There were no arrhythmias nor were there ischemic EKG changes. Their conclusion, based on the small difference in time exercising, is that wearing a mask did not limit physical exercise capacity.

Thus, wearing a mask does not adversely affect your ability to exercise or participate in activities.

Eggs Are Safe & Delicious

A few years ago, while visiting my pug’s veterinarian to try and find a way to get the dog to eat while undergoing radiation therapy, he suggested, “Why don’t you scramble him some eggs? It’s a great protein source and doesn’t contribute to cardiovascular disease in canines.” I have to admit I was a bit jealous since I was avoiding eggs, using egg whites and Egg Beaters instead. Two recent studies suggest eggs are safe for humans too.,

The American Journal of Medicine, in the January 2021 edition, published a research paper by C. Krittanwong, MD and associates which looked at 23 prospective studies covering a median of 12.8 years and 1,415,839 patients. There were 157,324 cardiovascular events during the study period. “Compared with the consumption of no egg or 1 egg per day, higher consumption was not associated with significantly increased risk of cardiovascular disease events. Higher egg consumption (>1 egg per day) was associated with a significantly decreased risk of coronary artery disease compared to no egg or one egg per day.

A study with similar results was published in the March 2020 edition of the British Medical Journal in a study involving 14,806 patients over 32 years. “Moderate egg consumption is not associated with increased cardiovascular risk overall.”

The message is clear, eggs are a fine source of protein in moderation.

Safety & Efficacy of Lowering Lipids in the Elderly

I am bombarded regularly by older patients, their adult children and various elements of the media with complaints that elderly are taking too many medicines. Poly pharmacy is the word they use and the first prescription medications they want eliminated are their cholesterol lowering drugs – either a statin (Lipitor, Zocor, Pravachol, Crestor , Livalo or their generic form), Zetia ( Eztimebe) or the newer injectable PCSK9 inhibitors Repatha and Praluent. Is there an age that we should stop these medications? Is there benefit in the elderly to continue taking them? Should we start these medications in the elderly if we discover they have high cholesterol and vascular disease?

A recent study was published in the prestigious Lancet medical journal. The authors looked at 29 trials with 244,090 patients. From this pool there were 21,492 patients who were at least 75 years old. Half of them were on oral statin drugs and the others were on Eztimebe or PCSK9 inhibitors. They were followed from 2 – 6 years.

The results showed that for every reduction of LDL cholesterol of 1mmol/L there was a 26% reduction of in major adverse vascular events. These numbers were similar to those in younger patients. The data also pointed out that these patients had a significant reduction in cardiovascular deaths, myocardial infarction (heart attacks), strokes and the need for heart surgical revascularizations. It was extremely clear that if you are on a cholesterol lowering drug you should stay on that medication despite your age!

A study in JAMA internal medicine, authored by LC Yourman, answered the question of whether you are too old to start on a cholesterol lowering drug. They found that it took 2.5 years before the cholesterol lowering medicine reduced your risk of a major cardiovascular event. Their conclusion was that if you are 70 or older, and your lifespan appears to be greater than 2.5 years, you should start the medicine.

Obstructive Sleep Apnea Surgery vs. CPAP? Daytime Anti-Snoring Device?

Obstructive sleep apnea is now epidemic in a population where it runs hand-in-hand with obesity, which is also an epidemic. The consequences of untreated sleep apnea include daytime somnolence, cardiovascular, neurological and endocrine complications.   One of the hallmark signs of obstructive sleep apnea (OSA) is snoring. 

The US Food and Drug Administration (FDA) recently approved an oral device to be worn during the daytime to reduce and/or eliminate snoring. The device is called eXciteOSA made by Signifier Medical Technologies.  The device is a prescription item which will be used by sleep specialists, dentists and ENT physicians.  It has four electrodes that deliver a series of electrical stimuli to the tongue with rest periods in between. The stimulation over time improves tongue function preventing the tongue from collapsing backward into the airway and obstructing it during sleep.  The device is used for 20-minutes once a day, while awake, for six weeks and then once a week thereafter. It is designed to be used in adults 18 years of age or older with snoring and mild OSA. Think of it as physical therapy for the tongue.

The device was tested on 115 patients, 48 of whom had mild obstructive sleep apnea plus snoring. The others were all snorers. The snoring was reduced in volume by more than 20% in 87 of the 115 patients. In the group of patients with the diagnosis of OSA and snoring, the apnea-hypopnea index score was reduced by 48%

It is recommended that a thorough dental exam be performed prior to trying this device. The major side effects noted from its use were excessive saliva production, tongue discomfort or tingling, metallic taste, jaw tightening, tooth filling sensitivity.  No mention of the cost was included in the printed review.

The online journal Practice Update reviewed a JAMA Otolaryngology publication on the use of surgery to treat Obstructive Sleep Apnea versus using a CPAP machine. There are many patients who just can not wear the CPAP mask which is the first-line “gold standard” for treating OSA.  Most patients who spend 90-days adjusting to the mask sleep far better and look forward to using the device to obtain a restful night’s sleep. The study looked at patients who were at high risk for not being able to adhere to a CPAP use regimen. Soft tissue surgery to the uvula was found to reduce the rates of cardiovascular, neurological and endocrine systemic complications compared with prescriptions for CPAP in patients less likely to adhere to or use the CPAP mask. 

The takeaway message is clear. When a patient is unlikely to adhere to CPAP mask use offering soft tissue oral surgery should be offered early while treating the disease.

Can Smartphones & Fitbits Interfere with your Pacemaker or Defibrillator?

The February 8th edition of Medpage Today, an online magazine, published the concerns of cardiologist and electrophysiologist Joshua Greenberg, MD, about the magnet arrays in the new Apple iPhone 12 interfering with the function of pacemakers and defibrillators.

When a patient goes to their doctor, cardiologist, electrophysiologist, etc., and the physician wishes to turn off their pacemaker to look at the heart’s normal electrical activity, they normally place a magnet over the implanted device to deactivate it. The new iPhone 12 apparently uses an array of magnets around a wireless charging coil.

Dr Greenberg used the iPhone 12 to disable a Medtronic ICD. Once he brought the phone over the patients left chest the device deactivated. His findings were published in January in a letter to the editor of the journal Heart Rhythm. “This is a big deal because if the patient were to go into ventricular tachycardia or fibrillation during this time, they would just drop dead without receiving a life-saving shock from the ICD.”

Separately, electrophysiologist M. Eskander, MD tweeted a video showing an iPhone12 shutting off a pacemaker as well as if a magnet had been placed over it. Wristband magnets in Fitbit and Apple iWatches have been reported to deactivate Medtronic ICDs from 0.9” away due to their wristband magnets.

Phil Mar, MD , an electrophysiologist at Saint Louis University School of Medicine agrees that this is a previously unrecognized issue that needs to be dealt with. He suggests patients with implanted pacemakers and ICDs avoid purchasing an iPhone with magnets. He encourages their spouses or bed partners to follow the same advice to prevent deactivation when they roll over and get close. He emphasizes that this was not an issue with earlier model iPhones which didn’t have an array of magnets and was not seen in Apple iWatches without the magnetic wrist bands for charging. He is concerned that any cell phone, wrist band or watch using wireless charging may cause the same deactivation.

The author of the article, Anthony Pearson, MD made the suggestion that patients with pacemakers and ICDs should have their cardiologist or electrophysiologist routinely test their cell phones, Fitbits and iWatches’ effect on their devices at a planned routine visit and certainly immediately after implantation. He reminded us this does not occur in devices that do not have a magnet array which is most cell phones and watches.

There has always been a recommendation that if you have a pacemaker or AICD you use your cellphone in the ear opposite your pacemaker or device pocket and never bring it within six inches of the device.

Blood pressure measurement, its importance in reducing vascular disease & remote patient monitoring

An article published in the prestigious journal Hypertension looked at following blood pressure over a decade and the reduction in heart attacks, strokes and deaths if you were able to keep blood pressure under control. It talked about extending your life by over four years and the preventing vascular disease from developing for at least five years.

The authors looked at multiple blood pressure trials and noted the difficulty in relying on one office visit measurement periodically. They too noticed that certain patients were always higher in the office than at home and noted the problems with home blood pressure monitors including trying to decide if they were accurate and being recorded correctly. The result was that whatever reading they obtained at your visit, when looked at over a 10-year period, influenced your survival and cardiac events.

We too have struggled with this issue in our office. We ask patients to bring in their home blood pressure equipment so we can correlate the readings they get in our office on our equipment and their equipment. Just last night a patient with no symptoms and feeling well took his blood pressure and found it elevated. Rather than contact me or his cardiologist he ran to the Emergency Room. He waited hours, had multiple tests and by that time his blood pressure lowered they referred him to his doctors without intervening at all.

When needed, we have a patient use a 24-hour ambulatory blood pressure monitor. They wear it on their arm like a blood pressure cuff and it inflates six times per hour during daytime and four times per hour during sleep while measuring their pressure. There is a small recording device worn on their belt. After 24 hours, it is returned to our office and we print out the readings and obtain averages to help us determine just what your blood pressure really is. The equipment has a diary so the patient can note when stressful events occur and we can correlate it with the readings. The minor drawbacks to the equipment are its bulkiness, the need to keep it dry and the disturbance to sleep it causes as the cuff inflates and deflates.

To improve measurements, as well as capture other health metrics, we are introducing a remote monitoring smart wristband. We have identified a vendor who will supply you with the high-tech wrist band at no out-of-pocket expense to you. The wristband interacts with your iPhone or android phone.

The device measures and captures pulse, heart rhythm, blood pressure, blood oxygen level, and steps.  It even has built-in fall detection. The 2021 model, which will be introduced in a few months, has an EKG component to help us follow patients who get dizzy, faint or have documented heart issues. It will also capture body temperature. There is an optional blood glucose sensor monitoring device. The wristband is water resistant so you may shower with it.

Due to the Pandemic, and development of tele-health, Medicare pays for the monitoring if you wear the device a minimum of 16 days each month. Patients are asked to identify emergency contacts so that if you fall or if you have an arrhythmia, abnormal blood pressure, abnormal blood sugar, the monitoring call center contacts your emergency contact on record.

Your physician can view all the data on our computers. Certain private insurances pay for these services as well as Medicare. I will start wearing one and my wife will as well.

I will personally discuss this with each of you whom I feel will benefit from wearing the wristband as remote monitoring is proven to reduce hospital admissions and ER visits. If you have a chronic condition, disease or certain risk factors; it’s likely I will encourage you to wear the band.

Some patients have asked if the band has a panic button for you to push if you feel you need to such as after a fall. The technology senses if you fell and have not gotten up or if you are ill and calls your emergency contacts but it does not have a unique panic button to push.

We look forward to introducing this new remote high technology to improve your health, safety and peace of mind.