How much forgetfulness is fine? As people age, it’s common to forget little things here and there. But when such a habit grows, it could be more than a careless mistake. For about six months, 76-year-old Shivesh Dahiya was experiencing bouts of memory loss. He would forget to take his medicines, couldn’t recall people’s names and even sometimes miss the fact that he had eaten. His concerned son, Swapnil, consulted a doctor.
The diagnosis was early Alzheimer’s. Over 10 million senior citizens in India are suffering from dementia, according to a recent study published in the journal Nature Public Health Emergency Collection. The study was conducted by researchers from the University of Southern California and AIIMS-Delhi, in collaboration with 18 other institutes, including Mumbai’s JJ Hospital. At the current rate, their number is projected to reach 16.9 million by 2036. But all isn’t lost. This Mental Health Awareness Month, we look at the future.
● SLOWING IT DOWN: Researchers have discovered neuritin, a protein that could slow down cognitive decline by retaining neural linkages in the brain. It resists toxic chemicals such as amyloid beta plaques and disordered tau (protein) tangles that cause Alzheimer’s from disrupting brain cell connections .
● REVERSING Alzheimer’s: Research published in the journal CNS Neuroscience and Therapeutics, holds the incredible promise that Alzheimer’s can be reversed using gene therapy. They developed a new approach that targets the neuron-killing taus with a ‘gene-silencing’ method using a short bit of DNA or RNA, which stops the generation of more tau. A rare gene variant—Reelin-COLBOS—can play
a crucial role in brain cell development. Another team of researchers at MIT used links of peptides, short chains of 2 to 50 amino acids, to disrupt an overactive enzyme harmful to neurons found in the brains of people with the condition. A drug based on this research could reverse Alzheimer’s disease.
● PROMISING DRUGS: Thanks to an experimental medication named donanemab, the regression in the mental skills of patients and their ability to perform daily tasks was arrested by more than 35 percent in an 18-month clinical trial that concluded recently on 1,700 patients by US pharma giant Eli Lilly. This January, a new Alzheimer’s drug called Leqembi was launched, which targets the accumulation of beta-amyloids in the brain.
● INNOVATIVE THERAPIES: Researchers at McMaster University, Ontario, are using sports as an experimental field to treat Alzheimer’s. They believe ‘orienteering’—navigating unfamiliar territory by running fast and finding a series of markers using only a map and compass—can effectively check neuron degeneration by exercising the brain while exercising the body. The best athletes during orienteering will effortlessly and swiftly juggle multiple mental tasks to make quick decisions while traversing the terrain at high speed.
A similar study found that bilingualists, who have the skill to rapidly switch between two languages, can use similar tactics in daily mental and physical tasks to delay dementia. Scientists have created the first highly mature neurons from stem cells, which promises potential transplantation and injection therapies for neurodegenerative diseases.
They took the cue from ‘dancing molecules’ procedure to treat spinal injuries wherein mobile nanofibres could communicate with cells to start repairs on an injured spinal cord. Research published in April in the journal, Brain and Behavior, found evidence that light therapy—exposure to high-intensity artificial light—may reduce certain dementia symptoms. A medical headset to treat Alzheimer’s made by Cognito Therapeutics is being tested using light and sound therapy to boost cognition and arrest the neuron-decay.
THE PROBLEM WITHIN: More than 57 million people worldwide are reportedly living with dementia, for which there is no cure: a number that could triple worldwide by 2050, according to WHO. The disease can, at best, be managed with medication. Its progress can be delayed to a certain extent, but after a point, dementia becomes resistant to medication. The illness is challenging to diagnose because the symptoms are often subtle and can be mistaken as age-related issues, such as memory loss, frequent falls, loss of comprehensive abilities, degenerative muscle power, etc.
“People mostly believe that dementia and Alzheimer’s disease are the same, but there are many other brain diseases that come under the umbrella,” says Dr Rajashekar Reddi, Senior Director, Headache and Neuromuscular Disorders, Max Super Specialty Hospital, Saket, Delhi. He categorises them under different heads.
(1) Frontotemporal dementia (FTD)—a rare form of dementia caused by progressive nerve cell loss in the brain’s frontal lobes or its temporal lobes.
(2) Lewy body dementia, caused by abnormal deposits of the protein alpha-synuclein.
(3) Vascular dementia, caused by damaged blood vessels in the brain.
(4) Mixed dementia, a combination of two or more types.
Cerebral damage from hypertension has been proved to cause cognitive decline according to an international team of researchers, which examined the MRI images of more than 30,000 participants. A breakthrough discovery has identified nine specific areas of the brain damaged by high blood pressure, which could contribute to cognitive decline, thereby making intervention before neurodegeneration possible. VDAC1, a protein found on the mitochondria’s surface, acts as a gatekeeper for various chemicals and elements of brain function. Israeli geneticists at Ben-Gurion University of the Negev in Beersheba found that excess VDAC1 caused a passageway for vital proteins and DNA to exit the brain, causing cell death. Targeted therapy made important breakthroughs in models.
Environment-related issues such as air pollution are also risk factors. Researchers found that for every two micrograms per cubic metre (ug/m3) increase in average annual PM2.5 concentration, there was a 4 percent rise in the overall risk of dementia. The world is awash in micro and nano plastics (MNPs).
According to a 2022 study, published in the International Journal of Environmental Research, adult men and women are estimated to consume approximately 1,33,000 and 97,000 particles of these plastics respectively, from water alone every year. MNPs often break through the blood-brain barrier and contribute to neurological conditions. As many side-effects of Covid-19 remain unknown, research published in the Journal of Alzheimer’s Disease Reports has discovered that the virus accelerated dementia.
CAUSE AND EFFECT: In 1906, German psychiatrist Alois Alzheimer performed a brain autopsy on a patient who displayed ‘abnormal symptoms’ when he was alive—the first exploration of trying to understand the disease. More than a century later, the medical community is still trying. So far, amyloid beta plaques and tau tangles have been considered the main culprits. But a November 2022 study by Yale researchers, published in the Nature journal, found that it is the swelling caused by a byproduct of these plaques that could be the true cause.
Researchers are experimentally treating this inflammation to arrest the disease. In this scenario, a complex sugar molecule—glycan—could play a crucial role. Bio-scientists at Johns Hopkins Medicine are working on new drug targets based on this finding. The cause behind Alzheimer’s is the holy grail of neuroscience: US researchers have identified a route that begins in the gut and ends in the brain cells to release powerful pro-inflammatory toxins in brain cells as a contributing factor to the development of the disease. While a study in January 2023 by researchers at the Johns Hopkins Bloomberg School of Public Health found that older adults with hearing loss were more likely to have dementia, previous research published in JAMA Neurology found that wearing hearing aids and cochlear implants could reduce the risk of long-term cognitive decline by up to 19 percent.
The eyes have it too; tissue atrophy and inflammation in the retina are two key markers to measure cognitive decline. Physicians can also diagnose impairment after monitoring vocal patterns. The more the brain is stimulated, the less likely the chance of getting dementia. Results of a 2002 study published in the Journal of Alzheimer’s Disease Reports found that light therapy improved sleep at night and reduced depression and agitation in patients. Some research, however, has discovered a link between excessive daytime napping and dementia. Researchers from Cima University of Navarra, Spain, found that short, repeated exposure to menthol can improve cognitive abilities. Experts believe this may open up the doorway to using odours as therapeutic agents.
Apart from drugs, the human factor matters in dementia treatment. After Indore resident Prerna Jha’s father was diagnosed with muscular atrophy—a genetic cognitive decline of the muscles leading
to difficulty in speech, walking and other motor functions a support group of his peers kept him active. Recounts Prerna: “He would be socially active. This helped us manage his condition. He would play cards, solve puzzles, and regularly go to the movies.
These kept his mind alert. Since his condition couldn’t be reversed, it deteriorated leaving him bedridden for four months before he passed away last year.” In 2008, the Netherlands set up an innovative ‘dementia village’ called the Hogeweyk, which has a grocery store, movie theatre, barber shop, restaurant, residential buildings and plenty of public green spaces. The community has doctors, nurses, psychologists, physiotherapists and other caregivers. The internet is a friend to people with memory loss: a recent study published in the Journal of the American Geriatrics Society suggested that older people who regularly went online were less likely to develop dementia.
CARE AND CRISIS: Sixty-nine-year-old Jaiti Dasgupta was a high-school physics teacher who retired a decade ago. She lives alone in Pune, and her son, Mayukh, who’s an IT professional, lives in Seattle, US. In March 2022, Jaiti’s neighbour informed him that she was finding it difficult to manage her daily chores. Concerned, Mayukh reached out to Mumbai-based Dignity Foundation, which has a branch in Pune. The NGO provides companion services. Their volunteers run small errands like bank work and grocery shopping for the elderly.
More importantly, they provide much-needed friendship, someone to read to senior citizens, or simply spend time with them. To improve social connectivity, the NGO organises small get-togethers where the elderly meet once a month in person or on Zoom, play board games and watch shows and films. There is no better alternative to wellbeing than empathy: researchers at the University of Lethbridge, Canada, found tactile stimulation—gently massaging—could delay the onset of the condition by a year.
“The chances of getting dementia in older people double every five years. If the rate is 3 per cent for a 65-year-old individual, it will be about 20 per cent by the time they reach 80,” says Dr Mathew Varghese, Clinical Advisory Board Member, Sukoon Healthcare, a mental healthcare provider. Dementia rates are projected to double every 20 years, especially in the states with higher longevity like Kerala. A family history is bad news. In some cases, specific genetic mutations, neurodegenerative disorders such as Parkinson’s or Huntington’s disease, and chronic depression can add to the danger. Genes have a role to play. Excessive amount of a protein called amyloid-beta peptide, which results in the formation amyloid plaque—a contributor to Alzheimer’s—is one such mutative gene. “Leading
a healthy lifestyle and managing medical conditions can help reduce the risk,” advises Dr PN Renjen, Senior Consultant, Neurology, Indraprastha Apollo Hospitals, Delhi.He recalls the case of Mukta Singh, a 68-year-old woman with Parkinson’s.
A chance consultation with a neurosurgeon after experiencing numbness in one hand and poor grip in her fingers and toes led to a Parkinson’s diagnosis. Mukta was put on light medication since the doctor felt her condition was not severe. Nevertheless, she was mentally shattered and went into depression. Five years later, she developed Alzheimer’s. Kokila, her daughter and primary caregiver, says, “Diagnosed with a degenerative disease hit her hard. Constant low moods and medication that made her drowsy slowly led to a deterioration of her cognitive abilities. Given her history of depression, doctors fear that her decline could be rapid.”
The critically acclaimed Bengali film, Bela Suru, deals with a 70-year-old man looking after his wife with Alzheimer’s. The movie was hailed for its nuances; the many tender moments fraught with underlying tension. Though the woman depends on her husband for everything, she doesn’t recognise him—the dilemma of most such caregivers. Babu Joseph, chairman of the Bless Retirement Living in Kochi and president of the Senior Living Association of Kerala, says,
“The biggest problem is that geriatric care isn’t available in most cities. The care for a dementia patient usually falls on the family members, who are untrained. Every patient has different symptoms. We need professionally trained caregivers and proper training facilities.” The Indian healthcare system is waking up to the needs of elderly dementia patients. “While we’re a long way from producing enough trained personnel, private companies such as OSVI Healthcare, Max at Home, Saiman Healthcare, Dabur HCAH, etc. are working towards creating a sustainable homecare environment,” says Dr Prakhar Singh, DNB Emergency Medicine and Fellow in Critical Care Medicine, Attending consultant, Max Super Specialty Hospital, Saket, Delhi.
DETECT AND DIET: Can dementia be pre-diagnosed? The Mini-Mental State Examination (MMSE) assesses cognitive function in several areas, including orientation, attention, memory, language and visual-spatial skills. The test takes about 10 minutes and can help identify early signs of cognitive impairment. “Lab tests are being developed. If the disease is diagnosed early, we may delay its progression and manage the illness better,” says Dr Varghese.
A 2021 study published in the journal JAMA Network Open mentions a machine-learning algorithm to predict the development of dementia with 92 percent accuracy. A similar test is Montreal Cognitive Assessment (MoCA), which takes about 10-15 minutes and can detect the signs early. “Additional brain imaging techniques such as Magnetic Resonance Imaging (MRI) and Positron Emission Tomography (PET) scans are used to detect changes in the brain’s structure and identify the signs even before symptoms appear,” says Dr Renjen.
As with all disease management, a good diet can boost cognitive health. Dr Kiran Rukadikar, Bariatric Physician and Obesity Consultant, and founder of DietQueen App, says, “When it comes to nutrition, the MIND diet, which includes certain foods that are specifically related to brain health, will aid in reducing the risk.” The programme was developed by nutrition researcher Martha Clare Morris and her colleagues at Rush University Medical Center in Chicago in 2015.
“Incorporate leafy greens, berries, nuts, spices and seeds in your daily diet. Spinach, kale, collard greens, etc. contain a good amount of essential vitamins that may help in minimising depression and boost cognition,” says Dr Najeeb Ur Rehman, Senior Consultant Neurology, Marengo QRG Hospital, Faridabad. Spices such as cinnamon, cumin and sage are loaded with polyphenols—compounds that possess various health benefits concerning memory and brain health.
Of the brain health supplements available, CoQ is the most popular. A simple Vitamin D supplement could slow down the onset of dementia. It is little wonder that the brain health supplements market is predicted to touch $15,525.7 million by the end of this decade. Nutritionist Preety Tyagi, founder of digital healthcare startup MY22BMI, says, “Good cardiovascular health is necessary to keep blood pressure under control. This can be achieved through a healthy diet and exercise.”
RURAL REVERSE: Dementia affects both urban and rural populations alike. “Detection and treatment by specialists is available only in major cities. Hardly any medical services for dementia are available in rural areas,” laments Dr Varghese. Lack of awareness is leading to the growing number of undiagnosed cases. Many rural patients cannot afford the cost of prolonged care and medication. Urban sufferers have the advantage, thanks to resources like specialised memory clinics, neurologists and support groups.
Additionally, they have access to homecare services, assisted living facilities and specialised nursing homes. “Poor transportation options in rural areas is a hindrance for individuals with dementia and their families to travel for medical appointments. Social isolation is also more common,” complains Dr Renjen. Ignorance is no bliss for the affected. “There’s a negative attitude towards the disease in rural areas where the belief is that the disease is age-related ‘senility’, which cannot be improved. Most standard tests for detection are in English, which need vernacular options,” says Dr Reddi.
Neuroscience is one of the most rapidly expanding and heavily funded health vectors in the world. With around 100 billion nerve cells and over 100 trillion nerve connections, the human brain is the most complex organ in the body. The current century is considered the golden age of neuroscience with the 2010s called ‘the decade of the brain’. MIT scientists have developed a 3D brain map, which sees how decisions are made using bifocal microscopy. Inhibitors to arrest neurodegeneration unlock the secrets of super-agers who retain their youthful mental abilities well into their 70s and 80s. Although a miracle cure for dementia is not on the horizon yet, with new techniques, instruments and AI, there is hope that if the disease cannot be completely eradicated, it can be managed to afford the patient a longer and healthier life.
More than 10 million adults aged 60 or above in India suffer from dementia
Prevalence rate of the disease in senior citizens in the country could be 8.44 percent
The number of cases in India is expected to almost double by 2050
Worldwide, the caseload is set to triple to 153 million by 2050
A higher proportion of women than men suffer from the disease
Top 5 nations with Alzheimer’s
Finland 54.65
UK 42.70
Slovakia 38.15
Albania 36.92
Iceland 35.59
cases for every 100,000 people
Mobile Apps that Help
MemoClock: It allows caregivers to send messages to the patient’s phone, regarding medicine reminders, exercises, and the like
Train Your Brain: It has a variety of games to choose from
My House of Memories: The app brings up positive memories
Dementia Guide Expert: It offers caregivers tips on understanding the condition
Medisafe: It acts as a medicine reminder
Mojo: This helps caregivers understand the disease
MindMate: It has a plethora of brain games, a list of healthy nutrition, what regular exercises to follow and more
Lumosity: This helps to enhance cognitive skills
Foods to Include
• Green leafy vegetables
• Olive oil
• Berries
• Nuts
• Whole grains
• Beans and legumes
• Fish
• Poultry
• Wine, coffee, green tea, dark chocolate
Foods to Avoid
• Preservatives, refined oils, refined flours and artificial sweeteners
• Butter or margarine
• Deep-fried foods
• Cheese
• Red meat
• Processed foods
New Frontiers
A drug called Leqembi targets the accumulation of beta-amyloids in the brain
Scientists have created the first highly mature neurons from stem cells which promises potential transplantation and injection therapies for neurodegenerative diseases
A simple Vitamin D supplement could slow onset of dementia
An experimental medication named donanemab arrests regression by more than 35%
Bio-scientists are working on new drug targets, based on a complex sugar molecule—glycan
Short, repeated exposure to menthol can improve cognitive abilities
FDA has approved Rexulti as the first drug to treat agitation in Alzheimer’s patients. It has so far been used for schizophrenia and depression.
Early signs of Dementia
● Memory issues
● Behavioural or emotional problems, loss of empathy
● Visuospatial problems in locating objects and judging distances
● Language troubles such as difficulty in word finding, problems in comprehension
● Impaired reasoning and problem solving
● Facing an issue doing familiar tasks
● Confused with time or place
● Social withdrawal and isolation
WHO March 2023 report
More than 55 million people have dementia worldwide, over 60% of whom live in low- and middle-income countries. Every year, there are nearly 10 million new cases.
Dementia results from a variety of diseases and injuries that affect the brain. Alzheimer’s is its most
common form and may contribute to 60-70% of cases.
It is currently the seventh leading cause of death and one of the major causes of disability and dependency among older people globally
In 2019, dementia cost economies globally $1.3 trillion, approximately 50% of these costs are attributable to attention provided by informal carers (e.g. family members and close friends), who provide on average five hours of supervision per day
Women are disproportionately affected by dementia, both directly and indirectly. They experience higher disability-adjusted life years and mortality due to dementia, but also provide 70% of care hours for people living with the condition.
(According to research published in the journal Neuroepidemiology and a Lancet report)
“MRI and PET scans can identify early signs even before symptoms appear.”
Dr PN Renjen, Sr Consultant, Neurology, Indraprastha Apollo Hospitals, Delhi
“Private companies are working towards creating a sustainable homecare environment.” Dr Prakhar Singh, DNB Emergency Medicine and Fellow in Critical Care Medicine, Max Super Specialty Hospital, Saket, Delhi
“Spinach, kale, collard greens, etc. contain essential vitamins that may help in minimising depression and boost cognition.”
Dr Najeeb Ur Rehman, Sr Consultant Neurology, Marengo QRG Hospital, Faridabad
As its senior population increases, India is facing a mental health crisis with the number of dementia patients projected to reach 16.9 million by 2036. But new research holds out hope with unconventional treatments.