by Nicole D Anderson, Kelly J Murphy, and Angela K Troyer
Oxford University Press, 2012
Review by Roy Sugarman, PhD on Feb 12th 2013
Although this book is written for those with MCI and their carers, I imagine many others who worry about being over 50 and somewhat forgetful will also be reading the blurb in the bookstore. Three psychologists, Canadian based really, wrote this book for the population affected by this recent diagnostic category, many of whom may convert to a fullblown dementia rather than natural ageing effects or simply ageing without any sign of decline of cognitive function.
Certainly in the past, Snowdon and others, in their studies on ageing groups across the lifetime, have queried how some people retain resilience, as measured on formal testing, while neuroradiological imaging then autopsy revealed significant structural change in the absence of clinical decline. Recent reviews, my own included, have found several lifestyle risk factors in modern living that predict a high risk of conversion from normal brain, to MCI, and on to dementia: the rot in fact starts early, hence the warning signs of MCI are already a clearly formed offshoot of long tolerated factors, chief amongst which are the dangers associated with a sedentary lifestyle, and insulin sensitivity, with sitting, diet and the threat of dementia thus interacting with a host of other factors to produce the epigenetic phenomenon. Although the risk increases with age, with one in 10 affected with MCI over the age of 65, the book relies on a clearly proven fact that this decline is not inevitable and stems from modifiable risk and behaviors. This is so much a metabolic issue that many authors are now referring to dementias as a kind of Diabetes Type III.
The first five chapters are thus spent on defining the field: namely MCI, how MCI differs from normal ageing, and how it then is different to dementia. The possible outcomes of the condition of MCI is thus then delineated, as well as the risk factors for both MCI and dementia, the to-be-modified ones. Now age is included as one of them, but as I have made clear above, age as a term here depends on what one has spent one's time doing while ageing. We know there are risks associated with English bus drivers that do not occur in ageing in English post men for instance. Nevertheless, it's a numbers game and the loss of brain tissue means less to be chewed up by tangles and plaques and hence more risk of running out of stock of cells. However, as noted before, some may show all the damage in the tissue, but none of the symptoms, with multiple reasons why, some still not clearly understood. However, and integrated approach is more likely to succeed in delaying the dangers. Sex, genetics, prior brain injury, are regarded as non-modifiable traditionally, but as I mentioned before, epigenetic science may hold differently. Modifiable risk factors mentioned here are the education and intellectual engagement which may stimulate brain growth or connectedness, and thus provide more for the numbers and resilience game, and vascular and metabolic factors will play their role, again subject to modification. Apathy and depression, and I would add loneliness, are also mentioned. The authors do mention that even gender is not entirely a non-modifiable risk as I have asserted, as on page 93 they refer to the different factors in men and women that predict MCI, which risks in themselves appear to attach to gender roles and gender based activities and not to the XX or XY genetic material alone. The differences are however more solidly based in the hormones and other factors of gender in Alzheimer's itself.
Obviously the way one sets about diagnosing the various aspect of ageing, MCI and dementia are critical, as defining some categories allows for both treatment strategies and also research into how one becomes the other. There are four separate subtypes, and so the box on page 144 will also show how drugs are applied as treatment modalities in those four types: Amnesic and Non-amnestic MCI in a single domain, and both again in multiple domains. Antihypertensive, antidepressant, cholinesterase inhibitors, statins, hypoglycaemic agents, the names tell you about the modifiable risk factors each medication is striving to adjust.
Since most people are seldom alone, even at the age MCI kicks in, the personal impact of MCI is a necessary field to explore, and living effectively with the multiple aspects of this, eg stress, and taking charge of your life when living with it, is part of the approach. However, it is section three of the book which then addresses the modifiable lifestyle preventative and ameliorating measures the afflicted, or worried about being afflicted, might take.
Acknowledging what I mentioned before, food as fuel for body and brain are both necessary as modifiable factors. The so called metabolic syndrome is discussed, with the impact of diet on so many factors, eg cardiac and diabetes, the role of clean eating such as the Mediterranean diet, are no so easy to apply as people have other risks associated with them, including their diet, movement, etc, that it is hard to partial out what is diet in a healthy society, and what is diet plus other aspects of that particular epidemiological group. Simple issues like girth can influence the outcome. Measurement and intervention can thus be easy, or at least simple. There are no wonder nutrients, so put away the resveratrol tablets. Controlling all the confounding factors is difficult, but still, there is no doubt in anyone's minds that diet and cognitive capacity are clearly linked. Since people who eat clean also exercise, the impact of either, both proven, is enhanced by the integration of both. Pretty much the only real evidence for supplements is Vit D3, a hormone really, and calcium. Getting enough Vit D from natural sources is hard, and made harder over 50, so supplementation is recommended. The authors do, at the time of writing, warn about animal fat, and things such as coconut oil: however, the Paleo diet is rising fast as a healthy diet, and coconut oil is being investigated as a possible treatment for Alzheimer's, so watch this space. Again, fish oil is not really evidence based in terms of its value here, but Gomez-Pinilla and other writers elsewhere would disagree. As usual, a single intervention in your health is unlikely to reap benefits, integrating multiple changes into your regime is more likely to reap benefits across all possibilities, eg stimulation, coffee, curcumin, movement, sleep, coconut oil and all kinds of other things noted by other authors to be of possible value from cinnamon to interval training. There is the usual attack on salt, but as recently published material on salt now suggests, this may be a red herring…which of course has Omega-3 so how bad can it be? This is a fast-moving field.
The next chapter predictably and correctly looks at exercise. Disappointingly, the authors do not look at the dangers of a sedentary life, but at the healthy aspects of various aspects of exercise. The issues in relation to cytokines, inflammatory agents, loss of lipase-inhibition, switching off of electrical activity, loss of insulin regulation and so on that are endemic to sedentary behaviour are not mentioned at all. This chapter could have done so much more.
Consequently the discussion of brain games on computers in the next section, which rightfully questions the value of this growing, new field, in cognitive engagement, misses out on the fact these are done sitting down: more valueless sitting perhaps, on top of every other sitting activity the elderly seem to love. This chapter does however look at the issue of cognitive reserve as well as aspects of living positively, such as social engagement, which dominates the following chapter.
The book is thus a simply told narrative of the essential facts, heavily biased I think towards the psychologists way of thinking, and thus of value more to the practitioner who may deal with such families, but does fail in truly providing an integrated body-brain framework for the condition, suggesting the three psychologists, in breaking out of their psycho-silo, still have a road to travel. The value of the book however does revolve around its MCI focus, as opposed to a more general dementia textbook, and thus helps clarify a barely 13 year old field. I think a following version should target more of the works of others, such as Cozolino, Cacioppo, Greenwood et al, all reviewed elsewhere on Metapsychology online and integrate more of their findings. More general works in publication at this time present, without targeting MCI alone, a less siloed, more integrated body brain view of building resilience, in fewer pages, but as I say, this book's value is in presenting the case for a more integrated view of MCI, which is welcomed.
© 2013 Roy Sugarman
Roy Sugarman PhD, Conjoint Senior Clinical Lecturer in Psychiatry, Medical School, University of New South Wales