In November 1901 a 51-year-old woman developed a cluster of mental symptoms which included memory impairment. She was admitted to the Hospital for the Mentally Ill and Epileptics, Frankfurt am Main, under the care of Dr Alois Alzheimer who had begun his medical career as a resident at this hospital in 1888.

After her death, her case became the subject of a remarkable lecture delivered by Dr Alzheimer on November 4, 1906. Alzheimer’s lecture included a description of strange  microscopic changes in the patient’s brain caused by the deposition of a ‘peculiar material’  in the cortex.

Alzheimer concluded his lecture by stating that this was a unique hitherto unrecognised disease process.  The lecture was published in 1907 as a paper in the Zeitschrift für Psychiatrie und Psychisch-Gerichtliche Medizin under the title ‘A characteristic serious disease of the cerebral cortex’.

The patient has been since referred to as ‘Auguste D’. Her case was the first case description of dementia which has now come to be known eponymously as Alzheimer’s Disease; this was at the suggestion of  Dr Emil Kraepelin, director of the Royal Psychiatric Clinic, Munich, who  described the  second case of dementia  in a patient named Johann F.

The story did not end here.  Auguste D’s case file was lost and only found 80 years later, in 1995, after a prolonged search. It was found, still in in good condition, in a blue cardboard file in the archives of the Frankfurt Hospital.  Dr Alzheimer’s detailed case notes make fascinating reading.

Dementia is not necessarily something that happens inevitably to old brains. You are more likely to lose your brain if you don’t use it

The rest is history. Once considered a rare disorder, Alzheimer’s  disease is now recognised as a major public health threat the importance of which has overtaken cancer and heart disease.  Yet Alzheimer’s  remains a baffling disease. It is characterised mainly by two features: the physical – in the form of  the microscopic brain changes  and plaques as observed by Dr Alzheimer more than a century  ago,  and the mental symptoms, characterised  by what is now referred to as ‘dementia’.

What has baffled doctors is the disconnection between the physical changes in the brain and the symptom of dementia. Put simply, you can have what is (black) humorously referred to as ‘brain rot’ and yet remain perfectly normal and mentally agile well into old age. In other words, many people may have the microscopic brain changes of Alzheimer’s disease but display no deficit in mental  function.

Clues to the disconnection between the brain changes and brain function are beginning to emerge and the two suggested reads impinge on this. While there is little doubt that the microscopic brain changes originally described by Dr Alzheimer are the culprit, it seems as though the brain abnormality needs  added factors to hasten  the appearance of dementia.

By far the most important of these factors is blood vessel disease (‘hardening of the arteries’).    Therefore, in keeping with the adage  ‘a man is as old as his arteries’ – a good start is to keep your arteries fit through  sensible diet, plenty of exercise and avoidance of smoking;  this will stack the odds against becoming demented in old age.

The first of the two suggested good reads is a recently published think-tank report: ‘The Environmental Dimension of Malta’s Ill-Health and Action to Prevent Obesity, Diabetes, Cardiovascular Disease and Dementia’. Like its long title, this is a lengthy and detailed report with no fewer than six technical supplements. It is a detailed and profusely referenced report that draws together many strands (or ‘lifestyle domains’) which can influence the occurrence of dementia. The other read is a recently published book by Jay Ingram called The End of Memory – the Natural History of Alzheimer’s – an easier read and not as depressing as suggested by the title.

Both the report and this book convey the same message: the way you live may  determine whether you will suffer from dementia in old age. It is a case of keeping dementia at bay. Both the book and the report extol a simple message: If you live healthily you decrease your chances of becoming demented in old age. Living healthily is a question of keeping mentally and physically active, eating a healthy diet rich in fish and vegetables, avoiding smoking and drinking moderately or not at all.

The evidence for exercise in preventing dementia is compelling (this is reviewed in Supplement I  of the report). As Ingram says, this comes as a surprise because people don’t really see a direct connection between physical exercise and the brain, but in fact exercise enhances brain blood flow and somehow promotes brain regeneration. Exercise also protects your arteries from atherosclerosis and, at the same time, diminishes the chances of getting diabetes by more than half – both of  these are contributing factors to the likelihood of developing dementia.

The other interesting facet is ‘idea density’ or ‘cognitive reserve’. Dementia is not necessarily something that happens inevitably to old brains. You are more likely to lose your brain if you don’t use it; this starts with a good school education, development of skills and remaining mentally active and socially integrated during the lifespan.

Read the book or the report  – or both. They may change your life.

The ‘Environmental Dimension of Malta’s Ill-Health and Action to Prevent Obesity, Diabetes, Cardiovascular Disease and Dementia’ report can be downloaded at: http://www.tppi.org.mt/index.php/reports/659-report-maltas-ill-health.

Dr George Debono is qualified in medicine. He held various posts in paediatrics in Malta and the UK, after which he carried out clinical research for Novartis  in Switzerland and Rhone Poulenc  in Denmark and the UK. In 1990 he retired to Malta and took up activities related to Malta’s welfare and environment with particular focus on health. He is a board member of the Today Public Policy Institute and founder member of FAA.

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