Brain Health: What’s the Heart Got to Do With It? Michael A. LaMantia, MD, MPH, AGSF April 17, 2019
Disclosures • None
Overview • Who I am and why I’m here • Aging: Global and American Perspectives • Health Care Provision for Older Adults: Reasons to Do This Correctly • Case • Brain-Heart Connection • Heart-Brain Connection • Case Conclusion • Summary Points • Questions
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“Grow old along with me! The best is yet to be.” Robert Browning (1812-1889) 5
Life Expectancy Changes • 1900-1902: 49 years • 1939-1941: 64 years • 1969-1971: 71 years • 2003: 77.4 years • 2015: 78.7 years Source: CDC 6
Aging: International and Domestic Scope • Baby Boom Generation • Born between 1946 and 1964 • Quickly approaching age of retirement 7
In 2000, Vermont ranked 26 th among states in the percent of population ≥ 65. Where do you think we will rank in 2030? • 1 st • 11 th • 21 st • 31 st • 41 st 8
Why Care about Aging? • Cost and Aging • Generally held as cohort ages (Boult 2001, Evans 2001): • Chronic disease accumulates • Disability rises • Costs increase • According to CDC, US health care spending will increase 25% by 2030 • Raises concern that disability and aging may threaten future solvency of federal health insurance 9
Our Future? 10
Conflicting Predictions • According to National LTC survey: • Disability rates are decreasing (Manton 2007) • Costs to maintain patients in non-disabled state are decreasing (Manton 2007) • Aging is not cause of increased costs • Care near death and not for all elderly patients is most expensive (Seshamni 2004) • Number of complex causes for increased costs • “The aging of the population is not an adequate explanation” of health care cost increases (Bodenheimer 2005) 11
Close Call? 12
Beyond Cost to Quality • IOM report Crossing the Quality Chasm (2001): • Identified provision of high quality medical care to general population as major challenge • Vulnerable older adults: • Are often dependent on others for assistance with ADL’s • Cannot participate in their own health care plan • Receive suboptimal care across a variety of settings (Jencks 2000, Wenger 2003) • IOM report Retooling for an Aging America (2008) : • US health care system is unprepared to provide for the social and health care needs of our older adults 13
“The measure of a society is found in how they treat their weakest and most helpless citizens.” -James Earl Carter 14
The Case of Mrs. S. • 75 year old woman • Presents to geriatrics clinic for annual visit • Past Medical History: • High blood pressure • High cholesterol • Prior small heart attack • Physical Exam: • Blood pressure 124/78 • Heart Rate 76 • Rest of exam unremarkable
The Case of Mrs. S. • MMSE: 30/30; no complaints of cognitive concerns • Mrs. S states: “I’ve heard that the heart and the brain are connected. I want to live to be 100. What can I do to promote better brain and heart health, so that I avoid developing memory problems?”
Evidence for Brain-Heart Connection
Evidence for Brain-Heart Connection “Every affection of the mind that is attended with either pain or pleasure, hope or fear is the cause of an agitation whose influence extends to the heart.” -Dr. William Harvey, 1628
Evidence for Brain-Heart Connection • Frontal cortex of the brain is connected by pathways to the heart. 1 • -the brain may modulate heart rate and heart rate variability • Wide array of triggers and biochemicals (some regulated by the brain) are implicated in sudden cardiac death. 2 • Emotion • Catecholamines • Melatonin levels 1. Thayer and Lane. Neuroscience and Biobehavioral Reviews; 2009. 2. Singh, Kartik, Otsuka, et al. Biomedicine and Pharmacotherapy; 2002.
Evidence for Heart-Brain Connection
Risk Factors for Heart Disease • High cholesterol • Diabetes • High blood pressure • Smoking • Metabolic syndrome (cluster of obesity, high blood pressure, insulin resistance, and cholesterol imbalance)
Potential Risk Factors for Dementia • High cholesterol • Diabetes • High blood pressure • Smoking • Metabolic syndrome (cluster of obesity, high blood pressure, insulin resistance, and cholesterol imbalance)
Potential Risk Factors for Dementia • High cholesterol: • Some studies have confirmed an association between high cholesterol and Alzheimer’s or vascular dementia; other studies have not. • Differences in findings may be influenced by when cholesterol is checked (patients with early dementia may have improved lipid panels than they may have had earlier in life) • Some studies suggest influence may be affected by ApoE status • Mixed information on the role of statins (cholesterol lowering medicines) in preventing/treating dementia • Concern has been raised for role of statins in inciting further memory loss • Mixed evidence on role of diet in the development of dementia
Potential Risk Factors for Dementia • Diabetes: • Associated with 50-100% increase in risk of Alzheimer’s • Associated with 100-150% increase in risk for vascular dementia • Not clear if treating diabetes more aggressively results in better cognitive outcomes: • In some studies, tighter control associated with better cognition • In other studies, tighter control associated with more low sugar events and higher risk of dementia.
Potential Risk Factors for Dementia • High blood pressure • Risk of dementia appears to be increased by both high and low blood pressure • Association is not linear • High Blood Pressure in Mid-Life Associated with 1.5x increase in risk for dementia • Optimal blood pressure may be 135/80 --- these data are from Indianapolis 1 • Treatment with blood pressure lowering medications is associated with better cognitive function 1 1. Liu, Gao, Hall, et al. Journal of the American Geriatrics Society; 2013.
Potential Risk Factors for Dementia • Smoking: • Data are conflicting --- some studies have suggested a link and others have not • One review study (of 19 other studies) found risk of 127% to 179% in older smokers of having dementia, vascular dementia, or Alzheimer’s compared to nonsmokers. • One reason for the conflicting results may be the role of Apo e4 allele --- this is still being sorted out.
Potential Risk Factors for Dementia • Metabolic Syndrome: • Definition: cluster of obesity, high blood pressure, insulin resistance, and cholesterol imbalance • In one study of 980 patients, Alzheimer’s presence was 250% among patients with metabolic syndrome compared to patients without metabolic syndrome • Other studies have not always found these same results
Audience Opinions • What is the role of these risk factors in causing dementia? • Isn’t it fascinating how “messy” and “fun” science can be? • Do you have other reflections or thoughts?
Back to our Case • Mrs. S. • 75 year old woman • Presents to geriatrics clinic for annual visit • Past Medical History: • High blood pressure • High cholesterol • Prior small heart attack
Back to Our Case • Her question: “I’ve heard that the heart and the brain are connected. I want to live to be 100. What can I do to promote better brain and heart health, so that I avoid developing memory problems?”
Your Call • How would you respond?
My Response • Review patient goals • Heart disease may impact your lifespan and quality of life greatly • Advisable to control risk factors for heart disease • Little to No downside (from the brain’s perspective) to pursuing control of your risk factors for heart disease • Let’s control your blood pressure and cholesterol • Let’s monitor for diabetes • Let’s keep you physically and mentally active
Summary • Connection exists between heart health and brain health • We are still discovering the exact nature of that connection • Taking care of your risk factors for heart disease is in your best interest --- it may also help preserve your brain too! • Good heart health as well as physical and cognitive exercise are all recommended activities to stay independent as we age
Questions/Comments • Thank you! • Email: michael.lamantia@uvmhealth.org 34
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