2. What is your Methylmalonic Acid level?
(Note: This is a laboratory blood test that requires an order by your health care provider)
 
This substance is an intermediate step in the production of ATP and the most sensitive test to determine the adequacy of vitamin B12. A deficiency in B12 is an independent cause of a potentially reversible dementia.

3. What is your Vitamin D-25 OH level?
(Note: This is a laboratory blood test that requires an order by your health care provider)

This test is the best indicator of vitamin D availability in our body. This vitamin is actually a hormone and has a powerful role in your immune status, and affects cognition, mood, energy, pain, and bone strength. While “normal” laboratory values can be as low as 25 ng/mL, target values for brain health are much higher.

4. What is your Total Cholesterol?
(Note: This is a laboratory blood test that requires an order by your health care provider. It is routinely tested and likely available in your medical record)

Cholesterol is a type of lipid, or fat, which is an essential part of all cells. Cholesterol is the raw material from which our body produces steroid hormones, like estrogen and testosterone, as well as the stress hormone, cortisol. High Density Lipoprotein (HDL) is often referred to as “good cholesterol” and is protective against cardiovascular and cerebrovascular disease. Low Density Lipoprotein (LDL) is often referred to as “bad cholesterol” and can cause cardiovascular and cerebrovascular disease. Cholesterol targets are different depending on a person’s age, health, and risk category and should not be viewed as absolutes.

5. What is your High Density Cholesterol?
(Note: This is a laboratory blood test that requires an order by your health care provider. It is routinely tested and likely available in your medical record)

Cholesterol is a type of lipid, or fat, which is an essential part of all cells. Cholesterol is the raw material from which our body produces steroid hormones, like estrogen and testosterone, as well as the stress hormone, cortisol. High Density Lipoprotein (HDL) is often referred to as “good cholesterol” and is protective against cardiovascular and cerebrovascular disease.

6. What is your Low Density Cholesterol?
(Note: This is a laboratory blood test that requires an order by your health care provider. It is routinely tested and likely available in your medical record)

Cholesterol is a type of lipid, or fat, which is an essential part of all cells. Cholesterol is the raw material from which our body produces steroid hormones, like estrogen and testosterone, as well as the stress hormone, cortisol. Low Density Lipoprotein (LDL) is often referred to as “bad cholesterol” and can cause cardiovascular and cerebrovascular disease.

7. How high is your level of anticholinergic medication burden(ACB)?
Check your score using an online ACB calculator, such as: https://www.acbcalc.com/

Anticholinergic medications block acetylcholine, an important neurotransmitter in your central and peripheral nervous systems and interfere with your brain working effectively. Acetylcholine levels decline as we age. People with Alzheimer’s disease, dementia associated with Parkinson’s Disease, vascular dementia, as well as other conditions, are known to have even lower amounts of acetylcholine in their brains. Consequently, preserving existing acetylcholine is a target for several dementia medications. However, many non-prescription sleep aids, allergy and cold preparations are very “anticholinergic.” They typically contain a class of drug called an “anti-histamine,” such as diphenhydramine (Benadryl). But while they are helping you sleep or drying up your runny nose, they are also depleting your brain of acetylcholine. In addition to the antihistamines, many prescription drugs have anticholinergic properties, including older “tricyclic” antidepressants and medications for urinary incontinence, Parkinson’s disease, COPD, and some GI conditions. The effects of these medications are cumulative, so that each one separately may not have such a great impact on acetylcholine levels, but the totality of them do. One goal of intervention is to reduce or “deprescribe” medications high in anticholinergic levels or find alternatives that do the same job but are less centrally anticholinergic and create less negative impact on your brain.

To measure your anticholinergic burden (ACB) you can follow this link to an online calculator (https://www.acbcalc.com/). You enter the name of each medication. If the name does not drop down from the menu, it has no anticholinergic effect. If the name appears, you click on it and see its severity-of-effect score from 1-3. Add up the scores to determine your Total ACB.

8. How often do you take prescribed benzodiazepine medications?
Benzodiazepines (BZ) are prescription drugs indicated for the treatment of anxiety, uncontrolled seizures of any cause, and alcohol withdrawal. Some prescription sleep medications also belong to this class. Common BZ’s include Valium (diazepam), Librium (chlordiazepoxide), Xanax (alprazolam), Klonopin (clonazepam), Ativan (lorazepam) and Restoril (temazepam). This class of medications is habit-forming, and has high abuse potential, so that the longer someone uses it, the more they need to take in order to get the same desired effect. Long-term use of BZ’s (more than 90 days) is known to cause cognitive impairment. If you are using this class of medication and want to discontinue it, you should only do so under the supervision of a health care provider. Do not stop a BZ “cold-turkey,” as this can be dangerous.

9. Do you have Type 2 diabetes or insulin resistance?
T2DM is a chronic medical condition that affects the way sugar (glucose) is metabolized by your body. When this condition is present, cells no longer have an effective response to insulin, the hormone that is needed to bring glucose inside cells to produce energy, or ATP. People with T2DM may actually be making more insulin than someone without the condition, but their cells are “resistant” to the effects of the hormone, which is why the earliest stages of this condition are referred to as “insulin resistance.” There is a genetic basis in over 70% of people who have this condition which decreases life span and increases risk of dementia. We measure the body’s response to insulin by checking the glycated hemoglobin in the blood, the HbA1c level. This represents an average of how “sugary” the red blood cells are over the past 90 days. Depending on your age and other health conditions, your doctor may have checked this in the last year. If not, now is a really good time, regardless of your age, gender, or weight.

10. Do you have hypertension or high blood pressure?
Blood pressure is the pressure of circulating blood on the walls of blood vessels when your heart beats (systolic) and the pressure when your heart rests between beats (diastolic). It is measured using a blood pressure monitor on your upper arm or wrist. Your health provider has very likely recorded your blood pressure at one or more visits. You may be able to check this, as well as your lab reports, by going to your online records or by calling your provider’s office. Be aware that different blood pressure devices can register different blood pressures on the same person, and that blood pressure varies by the physical position you are in, your activity level just before your pressure reading was taken, the time of day, and your anxiety level (“white coat syndrome”). If you are planning to take your blood pressure regularly, consider using the same automated cuff at the same pharmacy or grocery store each time, or consider buying one.

11. Do you have obstructive sleep apnea (OSA)?
Inadequate air flow to lungs while sleeping results in oxygen deprivation to your brain, called Obstructive Sleep Apnea (OSA). This is tested by an in-lab polysomnogram (PSG) or home sleep study, which monitors your breathing, heart rate, oxygen levels, and sometimes your brain waves. The study produces a score called the Apnea Hypopnea Index (AHI), the average number of times your brain is deprived of oxygen each hour while you sleep. Common symptoms include snoring, repeated awakenings to urinate (nocturia), awakening feeling tired, awakening with headaches, and dozing unintentionally when sitting or lying down. However, many people are unaware of their symptoms and the diagnosis is based on objective results from an overnight sleep test, not a survey of symptoms or bed partner report.

Sleep studies require an order or referral from a medical provider. You can start this conversation with your provider by reporting on your disrupted sleep, snoring, and nocturia. You can also download the STOP-Bang questionnaire, a brief screening test with 8 yes-no questions to give a rough idea of your risk of having OSA, but understand that this questionnaire misses the symptoms of nocturia and morning headaches.

12. How much alcohol do you consume?
Take an honest look at your drinking habits. Remember that one drink is calculated as 12 ounces of 4.5% alcohol beer, 5 ounces of 12% alcohol wine, or 1.25 ounces (one shot) of 70 proof hard liquor. Many craft brews have a higher alcohol content and many lite beers are lighter in calories but not so different in alcohol content, so the math remains unchanged. One more thing: like many people you may pour liquor with a heavy hand and without using a shot glass, so make the adjustment in your calculations.

13. Do you smoke or vape tobacco products?
Smoking or vaping of tobacco products (4 mg eLiquid = 1 pack of cigarettes) is the standard measure. Smoking or vaping tobacco is associated with significantly higher risk for dementia, often due to the relationship with precursor conditions, such as hypertension.

14. Are you overweight? What is your body mass index (BMI)?
Obesity is a major driver of health problems that cause cognitive decline, including hypertension, type 2 diabetes, sleep apnea, and sedentary behavior. If you are overweight, especially in childhood and midlife, you have a potentially improvable condition that could have widespread effects on how you live and how you think in later life. We recommend that you calculate your Body Mass Index or BMI, using your current weight and height measurements. Although BMI is not a perfect measure, it is a good place to start. Follow this link to the free BMI calculator provided by the National Heart, Lung, and Blood Institute, a part of NIH: https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

15. How often and how much do you engage in cardiovascular exercise?
A 2022 study¹ found that 9800 steps per day cut dementia risk in half while just 3800 steps reduced risk by 25%. When you calculate your activity, count any type of moderate cardiovascular exercise that raises your heart rate. Include brisk walking, running, swimming, biking, tennis, yoga, and tai chi, as well as resistance or weight training. Sometimes stretching counts. Yardwork that is physically active can also qualify, but don’t count sitting on your riding mower or playing golf if you ride in a cart.

Housework and gardening are always a question. For some people these can be a true workout, with a lot of physical activity, but for others a more sedentary and languorous approach that doesn’t provide much benefit. When looking at exercise, pay attention to and record what you actually do, not what you did in the past, what you wish you did, or what you plan to do. You can download a pedometer calculator app for your cell phone to record your steps and distance. You can also use a device such as Fitbit.

1.del Pozo et al, Association of Daily Step Count and Intensity With Incident Dementia in 78 430 Adults Living in the UK. JAMA Neurol. 2022;79(10):1059–1063. doi:10.1001/jamaneurol.2022.2672

16. How well and how much do you sleep?
Sleep is important for health. Valuable metabolic, emotional and cognitive functions occur while we sleep. Insufficient sleep levels and quality are linked to hypertension, diabetes, obesity, heart attack, stroke, and depression, which all impact dementia risk. Too little sleep and fragmented sleep increase rates of all dementias. We now believe that the magic number for most adults is 7 hours, plus or minus 2 hours. Sleeping 5 hours of less interferes with removal of cellular byproducts or waste through the glymphatic system. People with insomnia also rely on medications that can reduce cognition. Sleeping 9 hours of more often reflects inefficient sleep, depression, loss of interest in usual activity, and an increase in sedentary behaviors.

17. How is your diet?
Everyone has different advice about diet. Results are inconclusive with respect to any particular food, or combination, or calorie count specifically preventing or delaying the onset of dementia. For a complete discussion, please refer to our chapter, and just keep in mind sugars, simple carbohydrates, and transfats are really not good for anyone’s brain.

18. Are you vaccinated for flu, pneumonia and COVID viral illnesses?
Research reported at the 2020 Alzheimer’s Association International Conference showed a 17% dementia reduction in people with at least one flu vaccination, that more frequent vaccinations reduced risk by another 13% and pneumonia vaccination for people over 65 reduced risk by as much as 40%.

Four studies in 2021 and 2022 demonstrated significantly higher rates of dementia following COVID infection, particularly in older patients who were hospitalized.

19. Do you have regular dental hygiene?
Large scale meta-analysis¹ finds that periodontal disease, caused by P. gingivalis significantly increases the risk of dementia and represents an often overlooked prevention intervention.

1. Nadim R, Tang J, et al. Influence of periodontal disease on risk of dementia: a systematic literature review and a meta-analysis. Eur J Epidemiol. 2020 Sep;35(9):821-833. doi: 10.1007/s10654-020-00648-x. Epub 2020 Jun 12. PMID: 32533373.

20. Do you take precautions to prevent injuries?
Head injuries at any age, through auto accidents or sports injuries can result in increasing likelihood and earlier onset of dementia in older age. People over 75 have the highest rate of traumatic brain injury and account for a third of TBI hospitalizations. Even a hip fracture in a vulnerable older person can result in prolonged hospitalization, rehabilitative care, and a cascade of cognitive decline.

21. How much mental stimulation are you getting?
While the evidence that computer brain games, crossword puzzles, making changes in overlearned habits (hold a fork in your nondominant hand), or changing your driving route to school or work do not have a major impact on preventing dementia, we believe that new challenges, activities, jobs, hobbies, or approaches to old habits can add some benefit to other brain preserving health changes. Interpersonal interactive activities, such as card games, group discussions, working with others on a project are better than reading, crossword puzzles, or other solo activities that are often not as challenging. You will want to lean toward doing things that require problem solving, thinking in new ways, and developing new skills. We want to emphasize new activities, new learning, new experiences and opportunities. “New” stretches the brain and creates new synapses, the connecting points between neurons that are the basis of your brain’s ability to grow and stay young. You want to avoid periods of inactivity or repeating familiar and overlearned activities that keep you in a mental rut. Learn a new language, play a new musical instrument, try a new approach to a problem, start a hobby, take an online or in-person course, volunteer for a community-based event or activity. You may even want to take a part-time job, especially if you can develop or use a new skill.

22. How socially involved am I?
Involvement in organizations, friendship groups, clubs, family activities, preferably with face-to-face involvement is important for mental health and dementia prevention. Ideally, physical contact is desirable, although virtual engagement may be a necessary alternative. Being married or in a long-term relationship helps, but don’t do this just for dementia prevention.

23. How is your mental health?
A subjective sense of well-being, feeling safe, being in control and able to make your own choices, maintaining an optimistic outlook, adapting to change and challenges, and dealing with loss are all critical to taking care of your brain. We know that chronic depression, stress overload, and pessimism increase the risk for cognitive decline. You may benefit from meditation, yoga, and other forms of self-care. Even if you’ve never considered it before, you may want to think about professional support, as in counseling or psychotherapy. Having an objective, outside person with whom you can share your concerns can make them more manageable and often just the process of putting feelings into words makes them easier to understand and manage. You may also benefit from psychotropic medication if you realize that what worked for you before isn’t quite cutting it now.

24. How well can you hear?
Hearing loss, even at subtle levels, has emerged in the past few years as an important factor in dementia risk and part of a good prevention plan. Coincidental to this awareness the hearing aid industry has been deregulated, allowing people to obtain various grades of hearing aids without a doctor’s prescription, even online. While deregulation can reduce cost and increase access, we are unaware of any research showing that nonprescription hearing amplification can have the same dementia prevention benefit as a test performed by a well-trained audiologist and hearing aids specific to your needs. We recommend being tested by an audiologist at a hospital, an ENT office, a university or VA medical center, or even one of the big-box wholesalers, like Costco and Sam’s Club. If you have an objective hearing loss that can be improved by hearing aids, we urge you not to ignore this problem. Better hearing will often improve cognitive test scores, reduce the risk for dementia, and improve communication.

25. How well can you see?
Vision loss is an increasing problem related to aging. We encourage you to see an ophthalmologist, a medical doctor specializing in the eye, who can measure your visual acuity and also examine you for underlying visual changes that cause blindness and for which treatment is indicated. Such conditions include glaucoma, macular degeneration, and cataracts. Problems with our eye health are often related to underlying vascular factors and lack of oxygen. Decreased visual acuity, despite correction, is an independent risk factor for dementia.