Brain Health: Whats the Heart Got to Do With It? Michael A. - - PowerPoint PPT Presentation

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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5

Robert Browning (1812-1889)

“Grow old along with me! The best is yet to be.”

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• 1900-1902: 49 years
• 1939-1941: 64 years
• 1969-1971: 71 years
• 2003: 77.4 years
• 2015: 78.7 years

Source: CDC

Life Expectancy Changes

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Aging: International and Domestic Scope

• Baby Boom Generation
• Born between 1946 and 1964
• Quickly approaching age of retirement

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In 2000, Vermont ranked 26th among states in the percent of population ≥ 65. Where do you think we will rank in 2030?

• 1st
• 11th
• 21st
• 31st
• 41st

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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

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Our Future?

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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)

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Close Call?

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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
• lder adults

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“The measure of a society is found in how they treat their weakest and most helpless citizens.”

• James Earl Carter

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
• utcomes:
• 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 Indianapolis1
• Treatment with blood pressure lowering medications is associated with better cognitive

function1

• 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

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• Thank you!
• Email: michael.lamantia@uvmhealth.org

Questions/Comments