Authors: Majid Fotuhi
Many of my patients lead very active lives, and most want to continue to do so as they age. I’d like to do the same! Therefore, I don’t tell them not to ski or cycle or even to stay out of the hockey rink. Instead, I tell them to give their brains a thought whenever they engage in any activity.
That might mean forgoing certain activities, such as boxing and mixed martial arts. In fact, I think boxing should be banned. It is, after all, traumatic brain injury in action! But giving your brain a thought might simply mean reducing your risk by wearing protective gear when playing sports or engaging in any activity where head trauma is a possibility. (Horseback riding; riding a motorcycle, snowmobile, or ATV; biking; skating; and skiing are a few.)
If you’re thinking
nobody wears a helmet,
think again. Skiers and snowboarders aged eighteen to twenty-four—who traditionally have the lowest percentage of helmet use among all age groups—are increasingly donning helmets, according to the 2011 National Ski Areas Association’s National Demographic Study. In 2011, 48 percent of all eighteen- to twenty-four-year-olds interviewed wore helmets, a 166 percent increase in usage for the age group since the 2002-2003 season, when only 18 percent wore head protection.
Given what I know about the rising risk of falls as we age, I also encourage regular safety checks around the home for anyone over the age of sixty-five. I ask them a series of simple questions. Are there loose rugs in your home, or electrical cords that might trip you? Could you benefit from a grab rail in the shower or elsewhere?
I also, of course, encourage all my patients to build their brain reserves, regardless of whether or not they’ve suffered a TBI (though, having had one is just another reason to devote effort to building up a nice, thick buffer).
Getting Better
Serious TBIs may be so obvious that diagnosis is a no-brainer. But diagnosing milder injuries can be more challenging. Symptoms can vary greatly by person: concussion sufferers may have migraines, memory loss, nausea, vomiting, insomnia, bowel problems, difficulty with concentration, inner ear problems that cause imbalance, sensitivity to light and sound, anxiety, irritability, or mood swings. Often such symptoms are dismissed outright or attributed to other causes. I frequently meet patients who’ve experienced cognitive symptoms for years without ever connecting them to a head injury they had suffered.
One, a young woman named Angela, spent years moving from doctor to doctor in search of answers to problems that cropped up after she suffered a concussion in a car accident. Once polished and professional, Angela found herself increasingly confused and unable to function at work following her concussion. She frequently felt dizzy and nauseated and began to suffer from daily migraines. Sometimes her pain and confusion were so severe that she would lock her office door and lie flat on the floor with her eyes closed. Before long, she added anxiety and depression to her list of woes. Within two years of her accident, she had lost her job and her marriage had crumbled.
When she came to see me nearly three years after her concussion, Angela was beginning to lose hope of ever regaining her health. To her, it was clear that the headaches and dizziness that followed her car accident were a direct result of her concussion. She suspected, too, that her mental confusion was related, but the handful of doctors she sought out for help dismissed her concerns. Some thought allergies might be her problem. Since her brain MRI was normal, her primary care doctor suggested she was simply an “anxious young woman.”
She had, in fact, been through such a frustrating medical odyssey that when I told Angela her problems were very real and stemmed from her car accident, she put her head on my desk and cried with relief.
It’s patients like Angela that make me recommend to anyone concerned about concussion that they find a doctor who is experienced in treating TBI patients.
That experience is crucial to treatment, too. Not surprisingly, given the variety of symptoms, there isn’t a one-size-fits-all treatment option for concussion. Instead, each concussion symptom is addressed on its own. Migraine symptoms might be treated with medication, dietary changes, and treatment of insomnia. Anxiety or irritability might require counseling, stress-reduction training, or medication. Inner ear problems and gait imbalance might be corrected with physical therapy, and attentional difficulty might be treated with cognitive training. Often concussion patients are cognitively frail, so many of these treatments must proceed slowly and gently. But the end goal is the same: to treat symptoms and implement changes that boost BDNF, increase oxygen flow, and promote healthy brain activity. Put simply, these patients need to strengthen and grow their brains.
In the future, TBI patients may benefit from a number of treatment options now being researched. One possibility is progesterone, which may limit damage if given before an injury and speed recovery if given post-injury.
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There’s also work under way to determine if biomarkers in the bloodstream can be used to determine the severity of a TBI and gauge the effectiveness of treatment.
And there are signs that high doses of DHA given after an injury may also improve recovery.
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In one study by my friend and colleague Dr. Julian Bailes, now chairman of the department of neurosurgery and co-director of the NorthShore Neurological Institute in Chicago, head-injured animals were treated with omega-3 fatty acids, including DHA, for thirty days following injury. Compared to a control group of injured but untreated animals, those given omega-3s had less damage in their brains. In fact, their brains looked much like animals who’d never had a head injury. There are now clinical trials in progress to examine whether DHA can do the same in humans and how much DHA is needed to produce the desired result.
Bailes and others are also working on another solution: a new helmet with a built-in accelerometer to detect the force of a hit. The helmet tracks how many hits a football player has taken and measures the force of the hits. Measurements are sent to a handheld device on the sidelines. Coaches and doctors can then track a player’s accumulated hits—even silent hits—and assess the danger to the player.
Such tracking may be especially important given that in a majority of concussion cases CT scans or brain MRIs don’t show obvious signs of injury, which can make assessing the damage difficult. EEG brain mapping may also be developed further to help us with establishing a firm diagnosis of concussion, especially when MRIs are normal.
These are all future solutions, however, so I encourage all my patients—those with TBIs and those without—to adopt a better-brain lifestyle that maximizes brain growers and minimizes brain shrinkers. For those who have experienced a TBI in the past, a healthy brain lifestyle is all the more important. It may be the difference between crossing the cognitive decline threshold and not.
Can it really help? For the answer, I’ll take you back to Gary, whose cognitive skills were noticeably deficient for his age when he arrived for treatment and began his twelve-week brain fitness program. He was not physically fit at the start of his program—his fitness capacity, or VO
2
max, was just 59 percent—so getting him back in shape was a major goal. That job fell to my exercise physiologist, who worked with Gary to improve his VO
2
max by 5 percent every five weeks.
The physical effort helped to improve another of Gary’s problems: insomnia, which is sometimes a consequence of TBI. Gary also worked with our clinical psychologist to further improve his sleep, and he learned to meditate and de-stress. Weekly EEG neurofeedback sessions, meanwhile, helped to increase his healthy brain activity and retrain his brain, as did computerized cognitive training sessions.
Although Gary’s injuries had happened decades earlier, he still benefited from the marvel that is neuroplasticity. Three months after starting a brain fitness program, he had improved his cognitive scores significantly and reported feeling better than he had in years. Even his son, who’d been so discouraged at our first meeting, said his dad now seemed to have recovered to about 80 percent of his pre-illness level. It was a remarkable turnaround that spurred Gary’s primary care physician to call me and ask, with pleasant surprise, “What did you do with my patient?” Gary was, as his son happily told me, “a new man.”
Washing Away Your Brain’s Neighborhoods and Highways
A
FEW TIMES
a month I see a new patient who comes in for “walking problems.” One was Lara, a retired professor in her late sixties who arrived with her husband one afternoon for an appointment to discuss her difficulty with walking and balance. As I watched Lara approach, I could see she was unsteady on her feet: her gait was wide and wobbly.
As a part of my routine head-to-toe evaluation, I asked Lara about any cognitive issues she might have. It was then that her husband rolled his eyes and chimed in. “She doesn’t remember anything!” he complained. “She’s always repeating herself and asking me the same thing over and over.”
Lara shrugged and she and her husband laughed good-naturedly about her lapses. It seemed, to them, a funny aside, but Lara’s memory problems weren’t really cause for a giggle. Nor were they, as she and her husband thought, completely separate from her unbalanced walking.
She didn’t have vascular problems, wasn’t overweight, and didn’t have diabetes. It wasn’t until I asked a key question that I had a good idea of what was at the root of Lara’s problems. “Do you drink alcohol?” I asked.
She unabashedly answered yes, explaining that she regularly downed three to four stiff vodka cocktails a night. “How stiff?” I asked. “Really stiff,” her husband answered. Lara, it turned out, had been guzzling vodka every night for thirty years.
She was rarely drunk and had never considered herself to have a drinking problem, but an MRI revealed that her drinking had indeed been a problem. I could clearly see that the part of her brain for balance and equilibrium, the cerebellum, was profoundly atrophied. Looking at it, Lara shook her head slowly. “But I’m always hearing news stories that alcohol is good for you,” she said, genuinely dismayed.
Lara wasn’t wrong. A little alcohol
is
good for most people (although it’s not a significant brain booster and as such is low on my list of ingredients for a bigger brain). But crossing the line into alcohol abuse, perhaps even for short periods, quickly washes away those benefits. In fact, it shrinks the brain.
To the Top of the Curve, in a Bad Way
Lara could be forgiven for thinking that her nightly drinks might be beneficial. As you read in chapter 5, alcohol use, in moderation, has been shown to offer some neuroprotective benefit.
One well-regarded study published in the journal
The Lancet,
for example, studied a group of more than five thousand people over the age of fifty-five and found that those who drank one to three glasses of alcohol a day were significantly less likely—42 percent less—to develop dementia during the study period.
1
Just why isn’t clear, although scientists have suggested alcohol in moderation may help to increase HDL cholesterol, which in itself is beneficial to the heart (and, thus, the brain).
Whatever the reason, alcohol’s brain benefits disappear once you cross the line into alcohol abuse. Chronic, excessive alcohol use, for example, has been linked to a substantially greater risk of dementia later in life.
2
Other studies have offered more insight into exactly what happens in the brain, as you’ll read in a moment. Based on all the evidence, I consider alcohol beneficial in small doses and harmful in large doses. If you were to plot damage and alcohol use on a graph, for example, you’d end up with a J-shaped curve. Drink no alcohol and your brain will experience the usual degradation that happens with age; drink some and you’ll see reduced damage; drink too much and injury to the brain shoots through the roof.
How Alcohol Harms the Brain
We know that alcohol in excess is bad for the brain. But why, exactly, is that? Does alcohol go straight to the brain and zap brain cells dead? Or is it, to go back to our CogniCity model, wiping out neighborhoods and highways alike? As it turns out, alcohol does its damage in several different ways.
To start, alcohol abuse does kill brain cells, and it affects certain parts of the brain more than others. One is the cerebellum, the part of the brain responsible for eye–hand coordination and balance, among other things. Unlike a cerebellar stroke, which causes immediate symptoms, alcohol damage in the cerebellum may result in walking problems that gradually worsen over time. Alcoholics may also have trouble with physical tasks that require coordination and precision, such as putting a car key into an ignition switch or moving a soup spoon from the bowl to the mouth.
Alcohol abuse also clearly shrinks the thinking and problem-solving parts of the brain. In one study that measured the brains of 130 alcohol-dependent people, for example, researchers found significant thinning of the cortex, compared to a control group.
3
In another study, researchers found alcoholics had less grey matter, especially in the prefrontal cortex.
4
That reduction correlated strongly with poorer scores on tests that measured decision making. In other words, the smaller their frontal lobes, the poorer their ability to make decisions. Alcoholics also had smaller hippocampi.
Sadly, poor decision-making abilities make it harder for alcohol abusers to make healthy choices, such as quitting alcohol, eating a balanced diet, exercising, or avoiding physical injuries. Alcoholics’ gait problems may also increase their risk of falls, especially in old age, which may result in TBIs.