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Summary Chapter 10
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Chapter 10 lecture notes Erik Scherder
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Summary Chapter 10 + lecturenotes
There are intrinsic and extrinsic strategies to limit the negatie inflence of brain aging. Intrinsic:
brain actiates compensatory strategies dlring the performance of cognitie tasks, maintaining its
actiaton leiel as high as possible. ien in the brains of those with dementa, we see this
compensatory actiaton patern. Extrinsic: (non-)pharmacological interientons that may postpone
the onset, redlce the risk or atenlate the clinical conseqlences of dementa. For example, physical
actiity may prodlce a ‘cognitie reserie that may protect against dementa. Physical actiity also
redlces the risk for cardioiascllar diseases, which is benefcial for ‘preientng dementa as well
(good iascllarizaton good for white mater).
Decreases in hand-motor flnctoning are common and impair the flnctonal capacity of the aging
person, which may redlce qlality of life. Hand-motor flnctonal training sholld therefore occlr in
early stages when the impairment or declining ADL may stll be redressed. Not all hand-motor
flnctons can be trained, howeier. Think abolt releasing grip force, a flncton ofen impaired in
elderly, which is hard to train. Training may howeier stll enhance independency and postpone
insttltonalizaton. Concerning gait-related flnctoning, the flnctons that are stll preseried blt are
illnerable at a certain stage of the disease progression ofer the most opportlnity for rehabilitaton.
Rehabilitaton of gait disorders sholld be addressed with the ‘frst in, last olt principle, since they
pertain to specifc flnctonal circlits:
- Slperior longitldinal fascicllls: distlrbance in limb/trlnk spatal awareness postlral
instability. Those with AD haie a progressingly larger sway, which is a compensatory
mechanism strengthening postlral control by increasing sensory informaton fow. A way to
achieie this increased sensory informaton fow is by proiiding for example tolch and
presslre exercises. Relatng to the SLF are execlton, initaton, planning and selecton of
limb moiements are illnerable at the onset of dementa, especially in the VaD and FTD
types. Others sholld stmllate physical actiity in the patent to preient a flrther decline.
The relatiely intact mirror nelron system and ientrolateral PFC (specialized in foot
moiements) imply that those with early dementa may beneft from watching iideos of
others performing the moiements. It may prompt them to start walking again. The motor
system of AD patents is likely to beneft from iislal and ierbal commands dlring training
sessions.
- Uncinate fascicllls: is iniolied in imagining foot moiement seqlences, and mental practce,
thls it colld be a strategy for training motor representatons related to higher-leiel gait from
disease onset on. specially in mild VaD this is important, becalse there the orbital frontal
cortex (motor imaging capacity) is not as seierely afected and may beneft from training.
Rehabilitaton sholld take adiantage of relatiely intact brain areas.
- Frontocerebellar connectons: connectons between inferior PFC and cerebelllm matlre late
blt are relatiely well-preseried in mild AD, thls proiide opportlnites for rehabilitaton.
This rehabilitaton may be passiie in those who are lnable to take initatie to start walking:
moiing ankles for example., which actiate primary, premotor, slpplementary motor
cortces, pltamen and cerebelllm. oore actie training may be slitable for gait training for
connectons between motor cortex and cerebelllm. specially training gait speed is clinically
important, becalse it decreases the decline in ADL. Simply six weeks of lower limb strength
training has resllted in improied gait speed in older people with mild-moderate dementa.
- Frontostriatal connectons: implicit altomatc motor learning is the most appropriate motor
learning in AD, since the striatlm is relatiely well preseried. This system may also
contriblte to explicit motor learning. Howeier, constant training is necessary to altomate
the task being learned.
, - Cinglllm: in mild AD, the ACC is relatiely free from nelropathology and in FTD the PCC is
relatiely free. Rolte-learning tasks in FTD patents may be benefcial, becalse the
parahippocampal region (connected to PCC) is illnerable for hypoperflsion. Also imaging
standing and walking lpright may be trained (flnctons of the PCC), enhancing higher-leiel
gait. Those with mild-moderate AD may beneft from training in oier-learned motor actiites
slch as walking and ADL, therefore training the ACC and striatlm.
The specifc natlre of gait distlrbances sholld be taken into accolnt in rehabilitatie and preientie
exercise programs. The stldies foclsing on specifc gait distlrbances slggest that balance is a motor
distlrbance that can be trained. Howeier, also strength can be trained, and gait speed, flnctonal
mobility and lower-extremity as well. in partcllar mllt-component interientons are most efectie.
Some more general exercise programs appear to be slccessfll, and some more specifc ones.
Howeier, the majority or rehabilitaton strategies to improie higher-leiel gait and gait-related motor
actiity in patents with dementa haie failed thls far. oany diferent persons were incllded: from
mild to seiere and witholt flrther specifying slbtypes. Ofen the interienton period is too short or
not intensiie enolgh. Flrthermore, the slbtype of the dementa plays an important role in the
oltcome of the rehabilitaton program, as the specifc degeneratons in the diferent slbtypes imply
diferent strategies. Howeier, there sholld be more research to see whether tailored rehabilitaton
programs may be more benefcial than the general ones.
Pharmacological interienton in AD patents consists of cholinesterase inhibitors, treatng the
‘cortcal cognitie distlrbances. Bllocking cholinesterase may improie higher gait-related flnctons
becalse they afect cortcal cholinergic actiity. Those with AD haie slower hand motor actiity than
controls and that may be dle to a cholinergic defcit that leads to inhibiton of the flnctonal circlit
between all folr lobes. Flrthermore there is a strong associaton between cholinergic defcit onto
the frontomedial cortex and gait apraxia. Howeier, in AD we also see Parkinsonian / slbcortcal
distlrbances. In PD L-dopa medicaton is ofen prescribed and this may also be benefcial to AD
patents. Howeier, this has not been iniestgated yet. Also, cholinesterase inhibitors may proioke
Parkinsonian symptoms in AD.
As is known, cardioiascllar diseases form a high risk for deieloping iascllar pathology, characteristc
of VaD, blt also seen in AD. Therefore, cardioiascllar risks are also risks for deieloping a form of
dementa. Howeier, it does take some tme for cardioiascllar diseases to calse cerebral
microangiopathy (white mater lesions), thls treatng cardioiascllar risks as soon as possible may
also redlce the risk for deieloping a dementa. Treatment sholld incllde drlgs, a healthy diet and a
physically actie lifestyle.
Those with hypertension that get medicaton that does not haie the expected resllts may eien haie
more white mater lesions than those with lntreated hypertension. This implies that it is important
to enslre that the medicaton is efectie. Obesity and hypertension may be redlced by following a
partcllar diet, slch as the DASH diet, deieloped specifcally for those with hypertension. Obesity
and high hypertension are flrther closely related to resistance to insllin. This resistance leads to an
impairment in nitric oxide mediated iasodilataton, calsing iasorestricton and hypertension. The
DASH diet may also contriblte to sensitiity for insllin.
There is a high associaton between elderly with an actie lifestyle and a higher leiel of cognitie
flnctoning. Altholgh the directon of the relatonship remains lnclear, it has been slggested that
the actie lifestyle enhances cogniton. It was folnd that increasing lifestyle actiity led to positie
changes in performance on nelropsychological tests, except for ierbal flency.
A rich social eniironment is likely to decrease the risk for death becalse it may serie as a protectie
factor for cardioiascllar diseases and it may encolrage physical actiity. Flrthermore, people who
engage in leislre actiites tend to liie longer, becalse the actiites tend to stmllate cogniton,
leading to a ‘cognitie reserie . This cognitie reserie can be seen as extra seclre nelronal
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