Today is the first day of a series of videos about preventing and reversing cognitive decline. The website is here:
http://event.awakeningfromalzheimers.com/

Today's episode was a start, briefly discussed the importance of reviewing a person's medications to make sure there isn't a combination that might worsen cognition, and the importance of optimizing blood sugar and sleep. I believe this is going to be worthwhile, and easy to watch. There are many episodes, and it will be an investment, but so far, it looks informative.

In November 2014, neurologist Dale Bredesen M.D., published the first article on reversing cognitive decline. Using a combination of approaches centered on lifestyle and supplements, 9 out of a total of 10 patients reversed their dementia, and 6 of them even went back to work (1).

I was very excited when I read that article, especially because Dr. Bredesen’s approach fits so well within a functional medicine framework. I couldn’t wait to put it into practice and wrote a blog post about it (some-approaches-can-reverse-cognitive-decline.html).

Since then, I have taken Dr. Bredesen’s 3-day training for health care providers who want to apply the Bredesen protocol (now called “ReCODE”, for “reversal of cognitive decline”). I have also been seeing several patients for a few months and noticing some encouraging early results. A few patients are just starting to receive results of blood tests that will help us focus our efforts at reversal.

In August 2017, Dr. Bredesen published his book “The End of Alzheimer’s: The First Program to Prevent and Reverse Cognitive Decline.” The book promptly sold out on Amazon but should be in stock again in early September. It is also available as a Kindle version, which is what I got. Though I had already spent many hours studying this information and organizing it to make it usable, I still found the book highly valuable. I also read it with an eye to considering whether it might be possible for many people to implement ReCODE on their own.

WHAT YOU NEED TO DO
What is the ReCODE approach? Basically you put into place universally beneficial habits (sleep, exercise, diet, stress reduction), and add supplements, alongside repairing dysfunctional processes (digestion, hormone function, processing of toxins) to the point that a number of blood test values are “optimized.” The ranges used by conventional labs are not sufficient here – we are looking to reverse illness so everything has to be “optimized.” And then you add supplements and herbs which in sufficient doses are known to enhance cognitive function. As you will see, the devil is in the details, but if you understand cognitive decline, it’s obvious that this would be the way to go.

“The End of Alzheimer’s” starts by reviewing the current beliefs about dementia – as summarized, for example, on the web page of the Alzheimer's Association – stating that basically, Alzheimer’s Disease is considered incurable and lacks effective medications to manage its symptoms. A search for “Bredesen” on the Association’s website turns up some references to grants from a decade ago, focusing on basic research rather than clinical research. I could not find the 2014 article mentioned above, and the subsequent clinical articles authored by Bredesen (2), (3).

One chapter of Bredesen’s book focuses on how a dementia patient feels. I loved this analysis: until now, people were not able to report on how things felt while they were in the throes of this disease because they never regained enough clarity to make the comparison. There’s nothing more compelling, once you have recovered a function, than to look back and remember how things were when you had lost it. For example, “Eleanor” recounts:

• “Before I reversed, it felt like I had a filmlike gauze over my brain that kept me from really connecting with others and from being able to easily engage in normal conversational back-and-forths. […] I couldn’t have told anyone that all these things were problems last year. I couldn’t put it all together.”

I found this section deeply moving: this is why my colleagues and I are in practice, to make an impact as meaningful as returning a person to their life, their work, and their connections with loved ones. Witnessing that never gets old!

WHAT NOT TO DO
Another chapter outlines what most people do wrong that causes them to get ill, and much of it applies to Alzheimer’s, other dementias, and other conditions that involve inflammation (which is most other chronic conditions, from depression, to autoimmune disease, to joint and muscle pains and digestive issues). It's a funny chapter, and also poignant, because it describes the way we functional physicians go through life – seeing hidden dangers where there was previously routine: the morning mocha and danish pastry, tuna sandwiches, diet sodas, afternoon candy, pasta dinners, and mildewy basements. I have to admit, those were almost daily “exposures” for me for decades. Dr. Bredesen writes:

• “The bad news is that the more you see yourself in the lifestyle I described, the more certain you can be that it is already impairing your mental sharpness.”

Actually, I would say, that is the good news. I know firsthand how good it feels to improve your lifestyle even partially. Many people come for a consultation because they are in pain and fatigued, and also concentrating poorly and feeling apathetic. They are not yet demented and there are many steps we can take to prevent that from happening. But their early on-course indicator and source of motivation is that they soon begin to feel better in a variety of ways. It doesn’t always require a complete life transformation. Our bodies can be quite forgiving, and having witnessed this repeatedly, I have no trouble believing that we can reverse dementia.

A theme throughout the book is the near universal negative reaction of respected neurologists and people’s primary care physicians. It seems hard to believe that medicine would be so rigid, but at the same time, that is not entirely a bad thing. It would be a problem if we adopted new treatments without giving them much thought or study. However, from the point of view of functional medicine, a ReCODE type approach is completely in keeping with what we normally do successfully in pursuit of reversing other illnesses. The skepticism toward ReCODE is the same as that regarding reversing type 2 diabetes, or hypertension, or arthritis. Most people’s primary care and specialist physicians are very critical and remain in disbelief. Strikingly, they do not reach out to us to investigate, as though they were not interested. But I believe instead that they simply don’t trust themselves to figure out if something is really working: they would rather wait for an official guideline. The problem with dementia, as with many of the other “incurable” illnesses patients face, is that patients don’t have years to wait, and may even have lost faith in a system swayed by big business interests.

​THE SCIENCE BEHIND THE BOOK
Part 2 of the book delves into the science that explains how dementia comes about, and thus how these problems can be tackled and reversed. The science is very well laid out, with useful metaphors – some of which I immediately adopted with my “cognitive decline” patients. I find that knowing how something works improves my motivation to implement a complicated program. Dr. Bredesen compares cognitive decline to the “roof with 36 holes:” it’s raining in your house because the roof has many defects – not just a few. If you fix just two or three, it will continue to rain in your house. Another way I understand it is the problem of “feed-forward cycles” – to interrupt a negative feedback loop, you just need to stop one event from happening. But in a system of interconnected feed-forward cycles, you have to stop most of the links.

So ReCODE is very much the inevitable conclusion of Dr. Bredesen's years of basic research. The novelty here is not the belief that mercury, or mold, or B vitamin deficiencies, or lack of thyroid hormone, can cause dementia. These are well-established medical facts. The novelty is in demonstrating that even small alterations in these parameters (being in the “normal,” but not the “optimal” range) can add up and create devastating decline. Reductionist clinical experiments, where only a single parameter is changed, will often have negative results where a combination of changes would have succeeded. But that, again, is functional medicine, and Dr. Bredesen admits that he was influenced by his wife Aida, an integrative physician. It is Dr. Sid Baker’s old metaphor: if you’re sitting on three thumb tacks, removing one will not make you feel better. The argument from the conventional medicine side is that big enough studies will include enough patients who are lacking only one aspect to get picked up in the statistics. Unfortunately this is not how Alzheimer’s disease develops: you often need more than one impairment to develop it, and reversing it requires you fix them all – thus very few people get better when you address only one of their impairments.

In the book, you will learn about three major types of Alzheimer’s disease, as well as type 1.5, which combines type 1 and type 2. These three types are the ones most easily reversed. Now you begin to have a framework for the tasks that lie ahead, but it will require first figuring out what type you have, and this means laboratory testing.

NUTS AND BOLTS
There is no reason your primary care provider cannot order all the laboratory tests suggested in the book and use Dr. Bredesen’s optimal ranges to pinpoint sources of problems. There is a skill set that comes with fixing some of these deficiencies, but it is certainly a good first step to identify them. Insurance sometimes pays for this, and flexible spending accounts may cover the supplements that help address some of the problems found. But your physician will likely not order and interpret lab tests simply based on a book, because as I mentioned earlier, they are most likely waiting for an official recommendation from the American Board of Internal Medicine, Board of Family Physicians, or equivalent neurology association. And the expert panels are not yet convinced.

So, the question arises as to how realistic it is to think that many people would navigate this protocol on their own. It is a complex endeavor in the face of an emotionally charged situation. Nonetheless, some patients have done so, and I can’t think of any other way to bring about change than to empower patients to feel hopeful, and to pressure their physicians and insurance companies politely and persistently until more get on board.

By combining several direct-to-consumer sources like 23andme and DirectLabs or RequestATest, one can make some headway, assuming hormone status is optimal. If hormone therapy is needed, a physician's prescription for thyroid hormone, for estrogens, for progesterone, and/or testosterone will be required, and any physician would first have to be convinced that they are needed and safe.

The services of a Bredesen-trained health care provider can be expensive, so I would love to see a calculation of how much money patients save when we use tricks we know for less expensive lab tests, specific supplements. We also use our experience and expertise to avoid going down wrong paths. If anyone has already calculated the cost of getting these labs without a physician, please leave a comment.

I used a random few labs to get a quick sense:

TEST                                    IN MY PRACTICE    IF PATIENT ORDERS
total T3                                  $0-4                         Direct Labs: $49
free and total testosterone    $0-15                        Direct Labs $79
Hemoglobin A1C                   $0-4                         Direct Labs $119
Homocysteine                       $0-4                          Direct Labs $69
ApoE4  genetic test              $1-50                        $199 for 23andme

I believe you will spend a lot more ordering labs on your own than through a savvy functional medicine provider, perhaps in the order of $2000 more. Also, you will not be able to get all of them: I could not find the innate immune labs required for a diagnosis of mold impact on Direct Labs.

I imagine that Dr. Bredesen could not write a book where he tells people to go see a functional medicine physician (though he does provide a link in Addendum A). And the truth is I am hopelessly biased, as seeing individual patients is in fact how I make my living. But do take a look for yourself, and make your own decision.

Some of the tests mentioned do require a physician who knows enough integrative medicine to know of (and believe in) testing using Cyrex Labs, interpret integrative stool testing, prescribe the chelator for the urine heavy metal testing, etc. You may need a provider who knows how to take patients off proton pump inhibitors, how to control blood sugar and reverse prediabetes, how to use a low carb/high fat diet safely, treat for mold illness (CIRS – chronic inflammatory response syndrome), Lyme disease and co-infections, and mercury overload.

Those of us who practice functional medicine have had to learn each of the above since our graduation from medical school, as well as keep up with advances as would be required of any physician. The 25 annual hours that are mandated in order to keep our licenses fall far short — this is why we can’t accept insurance rates of reimbursement that are based on a model where a physician sees 20 patients a day.

HOW TO PROCEED
I believe that any hope of making ReCODE more affordable might lie in setting up group visits. Especially at first, it could be much more cost-effective to go through the evaluation and intervention with a group of patients and their caregivers. This will require that enough patients reach out to us to start setting up these groups. Some of my colleagues dream of a ReCODE “center,” where patients could go and attend a series of classes, be seen by physicians in a cost-efficient manner, and quickly be on their way to improving cognition.

“The End of Alzheimer’s” goes on to discuss the steps necessary to follow the protocol in great detail, and some common problems faced by those who have. In person, Dr. Bredesen is positive, encouraging, hopeful. He has witnessed miracles after a professional lifetime of seeing drug treatments fail. He has worked all his life to understand this disease, and the solution to the problem turns out to be a complicated one. As in other endeavors in life, it’s of little use to wish for what is not true to become true. Instead, we ought to “turn around and face in the direction the horse is going.”(4) This is one disease that cannot be solved by a single cutting edge pharmaceutical agent, not in 2017, but you don’t have to just decline and suffer. Commit to the  ReCODE protocol for 6 months, and then decide if what you lose in implementing ReCODE is worth the bargain of saving your brain.

ONLINE APPROACH
I have put together a video outlining how I plan to structure an online course to take patients through a protocol to reverse/prevent cognitive decline structured on Dr. Bredesen's approach.



REFERENCES

(1) Aging 2014 Sep;6(9):707-17.
Reversal of cognitive decline: a novel therapeutic program
Bredesen DE

(2) Aging 2016 Jun;8(6):1250-8
Reversal of cognitive decline in Alzheimer's disease.
Bredesen DE, Amos EC, Canick J, Ackerley M, Raji C, Fiala M, Ahdidan J.

(3) Aging 2016 Feb;8(2):304-13.
Inhalational Alzheimer's disease: an unrecognized - and treatable - epidemic.
Bredesen DE

(4) The Five Things We Cannot Change, David Richo, 2006