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Cognitive Decline and Dementia Cognitive problems need medical evaluation to determine their underlying cause. If several conditions are not diagnosed, there can be irreversible decline where this at one time could have been prevented. Alzheimer's disease is the most common cause of dementia, and while there are only a handful of conventional medical treatments available, they have some efficacy and new treatments are being developed. The same conventional medical treatments are often used "off label" to treat other types of dementias or cognitive disorders. There are several complementary and alternative treatments which have been studied, but their effects are also limited. These include supplements, "cognitive rehab", & exercise. In my practice I recommend these complementary and alternative treatments only to augment standard medical treatments when there is an actual diagnosis unless a patient is absolutely unable to tolerate standard treatments. In cases of mild cognitive decline which may not actually be associated with a dementia, complementary and alternative medicine may play a preventative role. While results may not be dramatic, most people I know appreciate the improvements. Like conventional medications used in psychiatric practice to treat cognitive disorders, it can be seen that supplements may similarly effect neurotransmitter systems including those for Acetylcholine and Glutamate. Included here are some of the supplements that may be useful in adult psychiatric practice. Please read the warnings and precautions described on the "Disclaimers" webpage, included on this page are several but not all risks, interactions, contraindications, and side effects. Some dosing guidelines are given, but dosing should be guided by your health care provider. Additional resources concerning efficacy, dosing, contraindications and safety guidelines can be viewed on the "Research & Evidence" webpage.
Ginkgo Biloba may help cognitive functioning,memory and may delay the onset of dementia. The Natural Medicines Comprehensive Database at www.naturaldatabase.com rates this supplement as possibly effective for cognitive function and Alzheimer's disease. The Natural Standard at www.naturalstandard.com gives Ginkgo an A rating (strong scientific evidence) for both multi-infarct dementia and Alzheimer's, a B rating (good scientific evidence) for cerebral insufficiency, and a C rating (unclear scientific evidence) for age-associated memory impairment, depression and seasonal affective disorder, and memory enhancement in healthy people. Ginkgo seems to decrease blood viscosity (a risk factor for bleeding especially if taking other supplements or medications that can thin blood, or if going for surgery) and increase mirocirulatory flow. Ginkgo may have have neuroprotective effects because of its antioxidant properties along with other possible anti-inflammatory mechanisms. In addition Ginkgo may improve cholinergic neurotransmission. Ginkgo may also be of some benefit in geriatric depression and also anxiety. Like many supplements it may need to be taken for a while to get any benefit. Ginkgo is containdicated with active bleeding or when taking coumadin. Ginkgo also increases risks with other anticoagulants where bleeding risks include subdural hematoma and hyphoma. There may also be problems with the concurrent use of NSAIDS along with other drugs as including diuretics, antidepressants, HIV medications, and acetylcholinesterase inhibitors. Side effects may include gastrointestinal problems, muscle spasms, skin allergy, HTN, dizziness, headaches, and seizures. Other risk factors include persons with systemic arterial hypertesion, diabetes, and seizures. Ginkgo typically needs to be discontinued at least 14 days before dental or surgical proceedures. A typical starting dose is 60 mg per day of a standardized extract containing 24 to 27% of ginkgo flavone glycosides and 6 to 7% triterpenes. Vinpocetine is used for memory enhancement. The Natural Medicines Comprehensive Database at www.naturaldatabase.com rates this supplement as possibly effective for dementia. It may help to increase cerbral blood flow. Vinpocetine may also have have some cholinergic activity and seems to protect neurons against oxidative stress. Like Ginkgo there are risks associated with vipocetine's blood thinning action and it must be used with caution when taking anticoagulants, and be discontiued generally at least 14 days before dental and surgical proceedures. Side effects may include gastrointestinal distress, dizziness, insomnia, dry mouth, lowered blood pressure including orthostasis, tachycardia, headache, and flushing. There has been a case report of reversible agranulocytosis. A typical starting dose is 10 mg twice per day.
Huperzine-A may help in both age related memory loss and Alzheimer's. The Natural Medicines Comprehensive Database at www.naturaldatabase.com rates this supplement as possibly effective for cognitive function and dementia. This supplement may have some neuro-protective properties. Like the prescription medicine Aricept it may block enzymes that break down acetylcholine which is important for memory. Like the prescription medication Namenda, Huperzine may also have N-metyl-D-aspartate (NMDA) receptor antagonist properties protecting against toxic levels of glutamate. Unfortunately, also like Aricept and Namenda it has similar side effects which may include transient dizziness, nausea, and diarrhea. Other risks include arrhythmias, seizures, asthma, irritable bowel syndrome, inflammatory bowel disease, or malabsorption syndrome. Huperizine may interact with anticholinergic medications, beta agonists, Namenda, and the acetylcholinesterase inhibitors. Typical doses are 50 mcg 1-3 times daily.
Phosphatidylserine research has demonstrated improved global functioning in Alzheimer's and age related cognitive decline. The Natural Medicines Comprehensive Database at www.naturaldatabase.com rates this supplement as possibly effective for age related cognitive impairment and Alzheimer's. Phosphatidylserine may also help with depression. This supplement which is a component of nerve cell membranes may help increase brain levels of neurotransmitters. It may also help to reduce cortisol levels. Side effects may include gastrointestinal upset and insomnia. Phosphatidylserine should be avoided with anticoagulants and also needs to be avoided in the antiphospholipid antibody syndrome. Typical dosing is 100 mg 1-3 times daily. CDP-Choline also known as Citicoline has shown evidence of efficacy in both Alzheimer's and vascular dementia. The Natural Medicines Comprehensive Database at www.naturaldatabase.com rates this supplement as possibly effective for age related cognitive impairment but with insufficient evidence for Alzheimer's. It seems to work by increasing energy at the cellular level in the brain, resulting in increased levels of neurotransmitters, in particular dopamine and norepinephrine. Nausea and diarrhea seem to be the most common side effects. There don't seem to be any major known drug interactions. Typical doses start at 500mg daily.
Fish oil contains omega-3 fatty acids which are thought to have several potential health benefits. They may normalize membrane sturcture in the brain and may also improve neurotransmitter uptake. Some studies suggest they may be helpful with mood disorders as well as cognitive disorders. The DHA component in fish oils seems most important in cognitive disorders. The Natural Medicines Comprehensive Database at www.naturaldatabase.com rates fish oil as having insufficient evidence for cognitive function and Alzheimer's disease and the Natural Standard at www.naturalstandard.com gives fish oil a C ranking for dementia (unclear scientific evividence for this use). These supplements can cause loose stools, nausea, hypoglycemia, hypotension, gastrointestinal upset, with an acidic "burping", and can also thin blood which can increase the risk for bleeding, hemorrhagic stroke, and surgical complications. As there may be increased bleeding risk, caution must be used with anticoagulants. Fish oil is containdictated in conditions where there is active bleeding. There are several potential drug interactions. There is some possibility that they supress natural killer cell activity. Fish oils must be discontinued before surgery and avoided in hemophiliacs. There is some possibility that they supress natural killer cell activity. Effective dosing starts at about 1 gm per day. Acetyl-L-Carnitine may be of particular benefit to elderly persons who may be depressed and cognitively impaired. It is rated by The Natural Medicines Comprehensive Database at www.naturaldatabase.com as having insufficient evidence for depression but possibly effective for age-related cognitive impairment and Alzheimer's disease. In part this supplement may work via the cholinergic and dopiminergic systems. While generally well tolerated potential side effects and risks include nausea, vomiting, agitation, vertigo, and seizures. There are multiple potential drug interactions. A typical starting dose is 500 mg per day. Vitamin B12 and Folate (folic acid) are often adminitered together and seem helpful in the treatment of cognitive disorders and depression especially when there is a deficiency which may occur in the elderly and younger persons with certain intestinal disease where absorption is poor. The Natural Standard at www.naturalstandard.com gives B12 a C ranking (unclear scientific evidence) for Alzheimers. The Natural Standard at www.naturalstandard.com ranks B12 as possibly ineffective for cognitive function (presumably in the absence of a B12 deficiency) and with insufficient evidence for Alzheimer's disese. It ranks Folate as possibly effective for depression and with insufficient evidence for cognitive function and Alzheimers. The Natural Standard at www.naturalstandard.com gives Folate a C ranking (unclear scientific evividence for this use) for both depression and and Alzheimer's. Deficiency of either B12 or Folate can lead to dementia. B12, folate, and thiamine (another B vitamin) are often also low in alcoholics who demonstrate cognitive impairment. B12 and folate are sometimes used to augment the effect of conventional antidepressants. Because B12 deficiency is associated with decreased absorption in the intestines, sublingual preparations are sometimes used. Folic acid supplementation alone my mask B12 deficiency and may lead to progression of neurological damage. B12 should not be taken with Leber's optic atrophy. High doses of folic acid (folate) may interact with other drugs. Vitamin E has antioxidant properties. It also thins blood which may be of some benefit for vascular dementias but is also a significant side effect with associated risk factors and may need to be stopped a month before surgery. Vitamin E supplementation has had mixed study results. It was once believed to be more effective than is now thought to be in dementia and there are concerns that it may increase the risk of mortality. The Natural Medicines Comprehensive Database at www.naturaldatabase.com rates vitamin E as as possibly effective for Alzheimer's disease and the Natural Standard at www.naturalstandard.com gives vitamin E a C ranking for dementia/Alzheimer's disease (unclear scientific evividence for this use). Besides risks when combined with anticoagulants, vitamin E may interact with other medications like neomycin, and may also have a negative impact on chemotherapy. Vitamin K deficiency, liver failure, and bleeding disorders are risk factors. Side effects include fatique, nausea, diarrhea, and abdominal pain when used at the relatively high doses thought to be needed to improve cognitive function (compared to the usual dosage required in the diet). Typical doses used as such range upward from 400 international units (IU) per day to a maximum of 1500 IU. Multivitamins with minerals may also be helpful in dementia, though their efficacy has not really been fully demonstrated. Nevertheless in dementia and also in other disorders there may be inadequate absorption of vitamins and minerals from nutrition. Care should be taken in persons already taking other vitamins.
Turmeric is found in mustard, Indian and curried foods. Tumeric seems to have antioxidant and anti-inflammatory activity. It has been used in Ayurvedic treatments. It now appears that it may have some value in preventing Alzheimer's by reducing Apo E4 levels. Risks include induction or exacerbation of gall bladder and bile duct problems. Tumeric may induce the passing of gall stones too large for the bile duct. Turmeric may inhibit platelet aggregaton and thus increase the risks when used with other anticoagulants as such. There are several potential drug interactions. Medical problems which may be exacerbated include gastric irritation, ulceration, reflux, nausea, and diarrhea. For cognitive problems a reasonable minimal dose is estimated to be 1000 mg per day. Coenzyme Q-10 may help prevent inflammatory damage to the brain and may slow progression in Alzheimer's disease and slow functional decline in Parkinson's. The Natural Standard at www.naturalstandard.com gives this supplement a C ranking (unclear scientific evividence for this use) for both Parkinson's and and Alzheimer's. There is some possibility of gastrointestinal side effects, increased bleeding and blood clotting (decreasing the effect of coumadin), and decreased blood pressure, especially when taking antihypertensives. Co Q10 could interfere with chemotherapy, and use with doxorubicin is contraindicated. At high doses Co Q10 might cause fatigue. Typically Co Q10 may be taken at lower doses such as 30 mg per day to avoid potential side effects and interactions. The doses typically used to try to help with Alzheimer's and Parkinson's is somewhat higher however, where in Alzheimer's 120 mg 3 times per day has been used and in Parkinson's up to 1200 mg in divided doses has been studied.
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