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Health Protocols

Age Related Cognitive Decline

Background

The brain contains approximately 100 billion interconnected neurons, which collectively assimilate information received from nerves throughout the body and external stimuli. In addition to neurons, the brain is home to specialized cells known as glial cells, mainly astrocytes and microglia, which play numerous essential support roles.9,10 Glial cells also participate in vital signaling processes within the brain.11

The Aging Brain

With age, the number of brain neurons decreases and the cells and tissues that support them deteriorate slowly after age 20 and more rapidly after age 60. By age 90, brain mass has been found to be decreased by 11% compared with individuals in their 50s.5 The majority of neuronal loss is in the cerebral cortex, where most information processing occurs, and the hippocampus, a brain structure involved in memory and learning.2,12,13

Aging is associated with functional brain changes as well. For instance, cerebral blood flow decreases and production of neurotransmitters is reduced. Also, the integrity of the blood‒brain barrier, which controls movement of cells and molecules into and out of blood vessels in the brain, weakens,2,14 and the phospholipid-rich myelin sheaths that protect neurons and facilitate signal transmission deteriorate.13,15

These age-related brain changes manifest in the diminished mental abilities typically associated with older age, namely reduced short-term and episodic memory, difficulty recalling words, slower reaction times, and possibly depressed mood.2

From Age-Related Cognitive Decline to Mild Cognitive Impairment and Dementia

Age-related cognitive decline is the term used to describe the natural diminishment in ability to learn, remember, and process information. Mild cognitive impairment is the condition characterized by cognitive changes that are more than expected for age, but are not debilitating. It is estimated that 10–20% of adults aged 65 years and older have mild cognitive impairment.16,17

When cognitive decline becomes severe enough to interfere with social and occupational function and the ability to live independently, the condition is called dementia.17,18 Dementia affects approximately 5–10% of US adults age 65 and older.17,19 Alzheimer disease is the number one cause of dementia in the elderly, followed by cerebrovascular dysfunction.14 Importantly, most people with age-related losses in cognitive function never develop these more advanced conditions.18,20

Distinguishing between normal age-related cognitive change and mild cognitive impairment is challenging, but a comprehensive assessment that includes a history of cognitive changes, physical exam, neurological exam, and cognitive function testing is the basis of accurate diagnosis.18

Table 1: Domains of cognitive decline and functional signs of impairment17

Cognitive Domain

Signs of Impairment

Executive function

Difficulties with:

- Planning

- Organizing

- Multitasking

- Following directions

- Keeping up with shifting conversations

Attention

- Normal tasks take longer or need to be simplified

- Difficulty focusing in conditions with multiple stimuli

- Distractibility

- Difficulty holding information in mind for tasks such as mental calculations or dialing a phone number

Visuospatial skills

- Getting lost in familiar places

- Difficulty using familiar tools or appliances

- Increasing need for notes and maps

Language

- Difficulty finding words

- Using words or phrases wrong

- Difficulty with written and verbal language comprehension

- More frequent grammatical errors

Memory and learning

- Difficulty remembering recent events

- Repeating oneself

- Misplacing items

- Losing track of actions that have already been done

- Increasing need for lists and reminders

Social cognition

- Disinhibition or apathy

- Loss of empathy

- Inappropriate behavior

- Loss of judgement

Risk Factors Associated with Cognitive Decline

Older age is the number one risk factor for age-related cognitive decline, as well as mild cognitive impairment and dementia. Women have a higher risk of dementia than men. Furthermore, a number of potentially modifiable risk factors for late-life dementia have been identified, many of which have their strongest impact on late-life cognitive function when they occur in midlife.21-23 These risk factors include:

  • Sedentary lifestyle21,22
  • Low educational attainment21,22
  • Smoking21,22
  • Obesity21,22
  • Insulin resistance and type 2 diabetes21,22
  • Hypertension21,22
  • High cholesterol levels21,22
  • Chronic kidney disease21
  • Atrial fibrillation (a type of arrhythmia)21
  • Cardiovascular disease24
  • Depression21
  • Sleep disorders25
  • Sleep apnea26
  • High homocysteine levels27
  • Heavy metal toxicity28

Sleep Medications and Cognitive Dysfunction

Although sleep disorders are a common contributor to both acute and chronic cognitive problems, some medications used to treat sleep disorders have been linked in some studies to increased risk of dementia. This includes prescription sleep medications, such as benzodiazepines, as well as some over-the-counter sleep aids.29-31

Benzodiazepines are a class of sedative medications that alter neurotransmission and are indicated for short-term treatment of anxiety and insomnia; nevertheless, chronic use of benzodiazepines is common.30 Long-acting benzodiazepines, like clonazepam (Klonopin) and diazepam (Valium), are more likely to contribute to dementia risk than those with a shorter action, such as triazolam (Halcion) and midazolam (Versed).30 A newer class of sedatives known as Z-drugs is approved for long-term treatment of insomnia, but some evidence suggests their use may also contribute to dementia risk. Examples of Z-drugs are zolpidem (Ambien), zopiclone (Imovane), and eszopiclone (Lunesta).29

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