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BBS3022 - Clinical and Personalized Nutrition Summary
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Summary of the 2nd course in the minor Nutrition at Maastricht University. Summary includes all the cases from the year , written by a graduate BBS.
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Case 12 - What’s good for your heart is good for your brain?LG1. How does normal brain aging work?
Dementia and mild cognitive impairment are both common during
aging. Some cognitive abilities have been found to be resilient to aging,
like vocabulary, and can even improve with age. Other abilities, like
conceptual reasoning, memory, and processing speed decline gradually
over time.
● The decline of abilities is different in every individual.
● It is important to realize that shrinkage and loss of neurons is
also a normal part of aging. Therefore, it is important to draw a
line between normal shrinkage and loss of neurons, and
extreme shrinkage and abnormal loss of neurons and
connections. This abnormal loss can be due to either:
○ Neurofibrillary tangles that destroy the connections
○ Lifestyle since you simply do not use the connections.
In dementia, you see abnormal loss of neurons, loss of connections,
enlargement of the ventricles, shrinkage of the outer cortex,
disappearance of the hippocampus, increased levels of beta-amyloid in
the brain (meaning decreased levels of beta-amyloid in the CSF) and
formation of neurofibrillary tangles.
Grey matter volume decreases after 20 years of age. In the prefrontal cortex, most of the atrophy occurs..
In the temporal lobe, there are more moderate changes, involving decreases in the volume of the
hippocampus. This decrease of hippocampal volume is due to a loss of neurons, which happens due to:
1. Infrequent cell division
2. The opportunity for mutations to arise and accumulate.
○ Beta-amyloid protein is accumulated in the brains of AD patients, thereby causing
neuronal death leading to Alzheimer’s disease. People who already have a higher amount
of beta-amyloids in the brain have a high risk of developing cognitive impairment over
time and can eventually develop Alzheimer’s disease, since high levels of beta-amyloid has
been associated with decreased hippocampal volumes and episodic memory.
Loss of hippocampal volume can also be due to a decrease in neuron size and the number of connections
between them. Neurons undergo morphologic changes with aging, including a decrease in the complexity
of dendrite arborization, decreased dendrite length and decreased neuritic spines. This contributes directly
to synapse density reduction.
With increasing age, there is a more substantial decrease (16-20%) in white matter volume than grey matter
volume. This decrease in white matter volume also includes decrease of parahippocampal white matter,
which causes decreased communication with hippocampal structures and thereby a decline in memory.
The pattern of cognitive change over time is explained by concepts of crystallized and fluid intelligence.
- Crystallized intelligence refers to skills, abilities, and knowledge that is overlearned, well-practiced,
and familiar, like vocabulary and general knowledge.
These abilities maintain stable or gradually improve
around 0.02-0.003 SD per year. It is due to an
accumulation of information based on life
experience, therefore causing higher scores of
elderly than young adults.
- Fluid intelligence refers to abilities involving
problem-solving and reasoning about things that
are less familiar and are independent of what one
has learned. It peaks in the 30s and declines at
BBS3022 - Clinical and Personalized nutrition Alexandra Aaldijk
, about -0.02 SD per year. Fluid cognition includes a person's innate ability to process and learn new
information, solve problems, and attend to and manipulate one's environment. Examples are
executive function, processing speed, memory and psychomotor ability.
Cognitive ability can be roughly caused by 60% due to genetics, and can be divided into specific cognitive
domains:
- Processing speed → The speed at which cognitive activities are performed as well as the speed of
motor responses. It starts to decline in the 30s and continues to decline throughout life. Many of
cognitive changes are due to a slower processing speed, which can negatively affect performance
on many neuropsychological tests designed to measure other cognitive domains.
- Attention → The ability to concentrate and focus on specific stimuli. Simple auditory span shows
only a small decline in late life. A more noticeable effect is found on more complex attention tasks,
including:
- Selective attention → The ability to focus on specific information in the environment while
ignoring irrelevant information. It is important for engaging in conversations in noisy
areas or driving a car.
- Divided attention → The ability to focus on multiple tasks simultaneously, such as talking
on the phone while preparing a meal.
- Memory → Recollection of events that happened in the past. Older people have more trouble with
working memory → the ability to momentarily hold information in memory while simultaneously
manipulating such information, like calculating a tip on a bill, or ordering letters and numbers
alphabetically. Memory can be decreased due to a lower processing speed, reduced ability to
ignore irrelevant information, and decreased use of strategies to improve learning and memory.
There is memory acquisition, which is the ability to encode new information into memory, decline
with increasing age. Besides acquisition, memory retrieval, the ability to access newly learned
information, is also declined with increasing age. Memory is made up of two forms:
- Declarative memory → conscious recollection of facts and events in the form of semantic
memory, which is involved in fund of information, language usage, and practical
knowledge like the meaning of words, and episodic
memory, which is a memory for personally
experienced events that occur at a specific place and
time, also called autobiographical memory.
- Nondeclarative memory → exists outside of a person's
awareness. It is remembering how to sing a familiar
song. Procedural memory is a type of nondeclarative
memory and involves memory for motor and cognitive
skills, like remembering how to cycle and tie a
shoelace. Nondeclarative memory remains unchanged
throughout life.
- Language has both crystallized and fluid cognitive abilities. Overall language ability and vocabulary
remains intact and stable during aging. There are two types of language skills:
- Visual confrontation naming → ability to see a common object and name it, which remains
stable until 70s and then declines.
- Verbal fluency → ability to perform a word search and generate words for a certain
category in a certain amount of time, which declines with aging.
- Visuospatial abilities → The ability to understand space in two and three dimensions. These
abilities remain intact, like object perception, which is the ability to recognize familiar objects like
things and faces, and spatial perception, which is the ability to appreciate the physical location of
objects either alone or in relation to other objects.
- Visual construction skills → The ability to put together individual parts to make a coherent
whole, which declines over time.
- Executive functioning/reasoning → Capacities that allow a person to successfully engage in
independent, appropriate, purposive, and self-serving behavior. It includes the ability to
self-monitor, plan, organize, reason, be mentally flexible, and solve problems.
BBS3022 - Clinical and Personalized nutrition Alexandra Aaldijk
, - Concept formation, abstraction, inductive reasoning (after 45 yrs) and mental flexibility
decline with age, especially after 70s.
- Ability to appreciate similarities, describe the meaning of proverbs, and reason about
familiar material remain stable.
LG2. What are some different tests to assess different cognitive domains?
The specific tests used to determine functioning of a certain cognitive domain and neuropsychological
assessment are demonstrated in Lecture 9.
They can diagnose dementia (including Alzheimer’s disease) also via other methods than assessments.
1. A sample of CSF is taken via a lumbar puncture to determine the amount of beta-amyloid in the
CSF. Low amounts of beta-amyloid mean that there is more beta-amyloid in the brain, which can
cause negative effects. Therefore, low levels of beta-amyloid in the CSF are an indication of brain
damage and possibly Alzheimer’s disease.
2. Functional magnetic resonance imaging (fMRI) can be used to see mentalizing capacity. In older
people this capacity is decreased and there is a decreased BOLD response, indicating
blood-oxygen level dependent response. This decreased BOLD response is a marker for metabolic
activity in the prefrontal cortex.
3. Positron emission tomography (PET) can be used together with radiotracers to identify
beta-amyloid plaques.
LG3. Can you prevent dementia? How does it relate to public health? (brain reserves)
The theory of cognitive reserve is a theory that explains how certain activities may prevent age-associated
cognitive decline. It proposes that some individuals have a greater ability to withstand pathologic changes
to the brain, like amyloid protein accumulation from a greater brain reserve. There was found to be a
passive reserve, referring to genetically determined characteristics like brain volume, number of neurons
and numbers of synapses present, and an active reserve, referring to the brain’s potential for plasticity and
reorganization in neural processing, thereby allowing it to compensate for neuropathologic changes.
- High levels of education, participation in certain activities, higher socioeconomic status and
baseline intelligence can protect against brain disease.
- Therefore, prevention focuses on:
- Cognitive stimulation, meaning that patients have hobbies or social interactions
- Enough physical activity, meaning going on walks or cycling
- Healthy diet intervention, including the Mediterranean diet and lots of vegetables
- However, prevention for AD is still in its infancy, since there are only few studies done so far, which
are inconclusive, have confounding factors, have a causality dilemma (did an activity prevent them
from decline or was the person able to do the activity because they did not have a decline) and
have inconsistent results.
Another theory of how activities may prevent cognitive decline is explained by the scaffolding theory of
aging and cognition (STAC), which proposes that alternative neural circuits are recruited to achieve a
cognitive goal.
Cognitive training was found to improve cognitive testing results and relies on cognitive training by teacher
showing strategies to improve memory, reasoning and speed of processing. This type of training can
minimize functional decline with advancing age in the future.
When looking at public health relations, it was shown that there will be an increase in aging of the
population, causing an increased amount of people with dementia, thereby affecting healthcare costs
making dementia a global public health priority.
- Patients with AD will gradually lose their abilities and become more dependent on others and show
changes in behaviour (aggression, shame, denial) → causing stigma
- Relatives and other supporters have to cope with seeing a family member or friend become ill and
decline. Also, they are more dependent and show changes in behavior.
BBS3022 - Clinical and Personalized nutrition Alexandra Aaldijk
, There is low public awareness that dementia risk may depend to some extent on lifestyle factors. Only a few
people know that there are modifiable risk factors that can impact the risk of developing dementia. This
causes person's at risk not seeking help, receiving insufficient care and support from environment. With
pharmacological, psychological, environmental and social interventions, the AD patients will have optimized
cognition and are less likely to have psychological symptoms.
There are several important notions for public health implementation:
1. The number of people with dementia will increase
2. Be ambitious about prevention → decreases risk of getting dementia
- Active treatment of hypertension
- More physical activity
- Reducing or stop smoking
- Treat depression, diabetes and obesity
3. Treat cognitive symptoms → offer cholinesterase inhibitors at all
stages, or memantine for severe dementia.
4. Individualise dementia care, so that there is medical, social and
supportive care tailored to unique individual and cultural needs
5. Care for family carers → since they are at a high risk of getting
depression.
6. Plan for the future with help of attorneys and clinicians for the
family to know wishes of the AD patient with respect to housing
and caregivers.
7. Protect people with dementia from self-neglect and
vulnerability, help them managing money and prohibit driving.
8. Manage neuropsychiatric symptoms, like agitation, aggression,
low-mood and psychosis via treatment with pharmacological
management.
9. Consider end of life, since dementia patients might not be able
to make decisions or express their needs and wishes with
severe dementia.
10. Technology → can improve care delivery, but does not provide
social contact, like reminders to take medication or devices to
easen certain tasks.
Since there is no cure and there are modifiable risk factors, there should
be preventive strategies to prevent this epidemy from happening.
Therefore, the certain risk factors should be managed:
- Depression
- Diabetes
- Hypertension
- Obesity
- Smoking
- Alcohol consumption
- High cholesterol / hyperlipidemia
- Renal dysfunction
- Coronary heart disease
- Inflammation in the brain
LG4. How does cardiovascular health relate to brain health?
(heart-brain connection)
The neurovascular unit is an interplay between neurons, vascular cells,
and glia, and ensures that the brain's blood supply matches its energy
requirements. The cells in the neurovascular unit increase locally during neural activity, and they are
supported by a local increase in blood flow due to neurovascular coupling / functional hyperaemia.
BBS3022 - Clinical and Personalized nutrition Alexandra Aaldijk
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