Walking While Counting Backward Could Diagnose Dementia

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By Dr. Mercola

About 0.2 percent of people in their 70s, and close to 6 percent of those in their 80s, suffer from idiopathic normal-pressure hydrocephalus (iNPH),1 a neurologic disorder caused by excess fluid on the brain that leads to disturbances in gait, urinary incontinence and dementia. When identified in its early stages, iNPH is treatable and the disease can often be reversed.

Unfortunately, it often goes undiagnosed or, because the symptoms mimic other neurological conditions, may be misdiagnosed, often as progressive supranuclear palsy, or PSP, a form of dementia caused by damage to nerve cells that currently has no cure.

“As of now, diagnosis is difficult because iNPH symptoms are similar to other neurocognitive diseases. To distingue the difference, excellent clinical skills and diagnostic/imaging modalities are required,” researchers wrote in Gerontology and Geriatric Medicine,2 but new research suggests a simple walking test may accurately diagnose iNPH 97 percent of the time.

Walking Test May Accurately Diagnose iNPH

Monitoring a person’s walking ability while doing something else, namely counting backward or carrying a tray, may be the key to diagnosing iNPH as well as distinguishing it from PSP. Researchers from the Ludwig Maximilian University of Munich in Germany monitored 27 people with iNPH, 38 people with PSP and 38 healthy volunteers, comparing their gait under different testing conditions.

Study volunteers were asked to walk at their preferred speed, a slow speed and a fast speed, as well as while counting backward or carrying a tray. Notable differences were identified, with the PSP and iNPH patients displaying poorer gait than the healthy volunteers. According to CNN:3

“Generally, patients with PSP tend to fling their legs forward while walking, and when turning, they do so abruptly and uncontrollably. By contrast, iNPH patients appear as if their feet are glued to the ground, and some swing their arms in an exaggerated way. Patients with PSP fall more frequently than those with iNPH, but in both disorders, hitting the ground is believed to be related to motor and cognitive impairments.”

The most notable differences were observed, however, during the dual-task tests, in which volunteers were asked to walk while doing something else at the same time. This proved to be more challenging for the PSP patients compared to those with iNPH. In fact, when PSP patients walked while counting backward, their pace slowed by 34 percent, compared to 17 percent for iNPH patients.

Similarly, compared to iNPH patients, PSP patients walked slower and had worsened gait overall when they walked while carrying a tray. By assessing patients’ gaits, the researchers were able to accurately diagnose patients with PSP or iNPH 82 percent of the time, but this rose to 97 percent when their scores on the dual-task walking test were factored in.

Study author Dr. Charlotte Selge told the Daily Mail, “People with PSP appear to be more sensitive to these dual-task walking tests than people with iNPH … Our findings suggest that adding these dual-task tests would be an inexpensive and effective way to improve diagnosis of iNPH.”4 With improved diagnosis comes an improved chance of reversing the condition, as treatment — surgical implantation of a ventriculoperitoneal (VP) shunt5 — works best when started early.

The surgery, which works by diverting cerebrospinal fluid, has been deemed successful in reversing iNPH symptoms in more than 80 percent of patients6 while other research described it as both an effective and cost-effective medical treatment that could add 2.2 additional life years and 1.7 quality-adjusted life years to a 70-year-old’s life.7 On the other hand, the Alzheimer’s Association gave a much less favorable report to shunt surgery for iNPH, stating:8

“The effectiveness of shunting in NPH has never been demonstrated in a randomized clinical trial. Most of these studies were small and followed people for a limited time. Available data suggest that difficulty walking is the symptom most likely to improve. Several studies found a significant rate of postsurgical complications. Findings also showed that short-term benefits of shunt insertion tended to decline over time.”

Early Warning Signs of Dementia

Many people worry if their forgetful moments are normal memory lapses or a sign of something more serious. Memory impairment is a hallmark of Alzheimer’s disease, the most common form of dementia, and is not seen as often in iNPH, which is associated more with executive frontal lobe and attention deficits.9 However, not every blip in memory is cause for alarm.

If changes in your memory or thinking skills are severe enough to be noticed by your friends and family you could be facing mild cognitive impairment (MCI). MCI is a slight decline in cognitive abilities that increases your risk of developing more serious dementia, including Alzheimer’s disease. If your mental changes are so significant that they’re interfering with your ability to function or live independently, it could be dementia. Warning signs of MCI or dementia include:

Difficulty performing daily tasks like paying bills or taking care of personal hygiene

Asking the same question over and over

Difficulty making choices

Exhibiting poor judgment or inappropriate social behaviors

Changes in personality or loss of interest in favorite activities

Memory lapses that put people in danger, like leaving the stove on

Inability to recognize faces or familiar objects

Denying a memory problem exists and getting angry when others bring it up

Whereas an estimated 6 percent of those in their 80s suffer from iNPH, Alzheimer’s affects 10 percent of people age 65 and older.10 The Alzheimer’s Association compiled these differences between symptoms of dementia including Alzheimer’s and typical age-related changes:11

Signs of Alzheimer’s/dementia Typical age-related changes

Poor judgment and decision-making

Making a bad decision once in a while

Inability to manage a budget

Missing a monthly payment

Losing track of the date or the season

Forgetting which day it is and remembering it later

Difficulty having a conversation

Sometimes forgetting which word to use

Misplacing things and being unable to retrace steps to find them

Losing things from time to time

What Causes Dementia?

The fluid buildup associated with iNPH typically occurs for unknown reasons. The cause of Alzheimer’s and other forms of dementia is also typically said to be unknown, although it’s estimated that genetics account for around 5 percent of Alzheimer’s cases.12 In reality, there are dozens of other factors that are also involved; genetics is only one small piece of the puzzle.

For instance, research presented at the 2014 Alzheimer’s Association International Conference (AAIC) revealed Alzheimer’s patients with TDP-43, an infectious protein, were 10 times more likely to have been cognitively impaired at death than those without.13 Mounting research also suggests Alzheimer’s disease is intricately connected to insulin resistance; even mild elevation of blood sugar is associated with an elevated risk for dementia.14

Diabetes and heart disease also elevate your risk, as all three conditions are rooted in insulin resistance. Arterial stiffness (atherosclerosis) is even associated with the buildup of beta-amyloid plaque in your brain.15

As such, according to Dr. David Perlmutter, a board-certified neurologist and author of “The Grain Brain Whole Life Plan: Boost Brain Performance, Lose Weight, and Achieve Optimal Health,” your diet is by far the greatest contributing risk factor. To prevent Alzheimer’s, you need to focus on a diet that powers your brain and body with healthy fats, not net carbs (total carbohydrates minus fiber), i.e., a ketogenic diet.

That being said, it’s a complex issue and Dr. Dale Bredesen’s ReCODE protocol evaluates 150 factors, including biochemistry, genetics and historical imaging, known to contribute to Alzheimer’s disease. He believes there are disease subtypes or combinations of subtypes that dictate which treatment protocol is best. For instance, Bredesen states that type 1 Alzheimer’s is “inflammatory” or “hot,” and patients present predominantly inflammatory symptoms.

Type 2 is atrophic or “cold,” with patients presenting an atrophic response. In type 3, or toxic “vile” Alzheimer’s, patients have toxic exposures. There’s also a mixed type, type 1.5, which is referred to as “sweet” and is a subtype that involves both inflammation and atrophy processes, due to insulin resistance and glucose-induced inflammation.

An algorithm is used to determine a percentage for each subtype based on the variables evaluated, and an individualized treatment protocol is created. For example, if you have insulin resistance, you want to improve your insulin sensitivity.

If you have inflammation, then you’ll work on removing the source of the pro-inflammatory effect. Oftentimes you’ll need to eliminate toxins and/or address leaky gut or a suboptimal gut microbiome. Interestingly, they also place great focus on the rhinosinal microbiome, the microbes residing in your nose and sinuses. Further, restoring mitochondrial function is a cornerstone of successful Alzheimer’s treatment, and one of the most powerful ways to optimize mitochondrial function is cyclical ketosis.

Screening Tests to Evaluate Your Alzheimer’s Risk

Alzheimer’s research suggests preclinical signs of Alzheimer’s disease may be evident as early as 20 years before the disease actually sets in, allowing for much earlier intervention if these changes are identified.16 However, normally by the time your memory begins to noticeably deteriorate, about 40 to 50 percent of your brain cells have already been damaged or destroyed.

Just as the simple walking test has the potential to identify iNPH in its early stages, it’s possible to gauge your risk of Alzheimer’s in order to take early action as well. Bredesen recommends the following Alzheimer’s screening test so you can evaluate your risk and then get on an appropriate program for prevention or, if you’re already symptomatic, reversal:

Test Recommended range

Ferritin

40 to 60 ng/mL

GGT

Less than 16 U/L for men and less than 9 U/L for women

25-hydroxy vitamin D

40 to 60 ng/mL. You can get test here.

High-sensitivity CRP

Less than 0.9 mg/L (the lower the better)

Fasting Insulin

Less than 4.5 uIU/ml (the lower the better)

Omega-3 index and omega 6-to-3 ratio

Omega-3 index should be above 8 percent and your omega 6-to-3 ratio between 0.5 and 3.0. You can get the omega-3 index test here.

TNF alpha

Less than 6.0

TSH

Less than 2.0 microunits/mL

Free T3

3.2 to 4.2 pg/mL

Reverse T3

Less than 20 ng/mL

Free T4

1.3 to 1.8 ng/mL

Serum copper and zinc ratio

0.8 to 1.2

Serum selenium

110 to 150 ng/mL

Glutathione

5.0 to 5.5 μm

Vitamin E (alpha tocopherol)

12 to 20 mcg/mL

Body mass index (which you can calculate yourself)

18 to 25

ApoE4 (DNA test)

See how many alleles you have: 0, 1 or 2

Vitamin B12

500 to 1,500

Hemoglobin A1c

Less than 5.5 (the lower the better)

Homocysteine

4.4 to 10.8 mcmol/L

Novel Methods to Help Diagnose Dementia

A mobile game called Sea Hero Quest, and its virtual reality sequel, may help in the search for a reliable method of early diagnosis of Alzheimer’s disease. The game tracks players’ spatial navigation abilities, which are among the first skill sets lost in dementia cases. Neuroscientists are hoping to use data collected from hundreds of thousands of players to identify a normal range of navigation skills and ultimately develop guidelines to identify dementia early on.17

Blood tests measuring brain proteins (lysosomal proteins) may also help predict Alzheimer’s up to 10 years before the disease develops. Another biomarker panel may predict the disease within a two- to three-year timeframe with over 90 percent accuracy; PET scans and retinal tests also offer hope of early detection. If you want to further test your own cognitive function, try the Self-Administered Gerocognitive Examination (SAGE) test.

It’s a 15-minute at-home test developed by Dr. Douglas Scharre of the Division of Cognitive Neurology at Ohio State University’s Wexner Medical Center. You can download the SAGE test from the university’s website. According to Scharre, this simple test correlates very well to more comprehensive cognitive tests and is an excellent way to get an early assessment of your cognitive function.

If taken at regular intervals over time, it can also serve as an early warning if your scores begin to decline. The only downside is that answers to the questions aren’t provided so to find out your score you’ll need to find a physician who can score it for you. The test is ultimately designed to evaluate your thinking abilities and help your doctor know if further evaluation is warranted. In addition to prevention and early detection, there are exciting treatment strategies in the works as well.

Photobiomodulation, which involves stimulation of the brain with near-infrared light, is among them and has been found to boost cognition and reduce symptoms of Alzheimer’s, including more advanced stages of the disease. Dr. Lew Lim has developed a device called the Vielight, which employs light-emitting diodes at these frequencies. Alzheimer’s patients using the device for 20 minutes a day report remarkably positive results. You can find more information in my interview with Lim, below.

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