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Monthly Archives: January 2022

Heart and Mind

02 Jan

Understanding and preventing dementia is something in which I have a strong interest since I’ve observed its enormous impact on patients and their families. Dementia is defined as cognitive impairment severe enough to interfere with daily life. There are multiple causes of dementia including Alzheimer’s disease and the accumulated effects of strokes called vascular dementia.

A recent study published in the journal Alzheimer’s & Dementia assessed the connection between having an elevated heart rate and dementia. Your heart rate or pulse is how many times per minute your heart contracts and pushes out blood to the rest of your body. Your pulse normally goes up with physical activity or stress as your bodies senses it needs more blood with oxygen. A resting pulse is your pulse when you aren’t engaged in physical activity.  This study performed in Stockholm observed 2,147 individuals 60 years old and older over a period of up to 12 years. It found that individuals with a resting heart rate of 80 beats per minute or higher on average had a 55% higher risk of dementia than those with a heart rate of 60-69 beats per minute. Individuals with higher resting heart rates were older, less educated, and more likely to be smokers and sedentary and to have hypertension. Since these are risk factors for dementia they could explain much of the association observed between having a higher resting pulse and dementia.

This study was observational so that it cannot establish a causal relationship between an elevated pulse and the risk of developing dementia. Nonetheless, here are my takeaways: First, an elevated pulse can be a marker of poor cardiovascular health. In a well-functioning cardiovascular system, the heart doesn’t have to beat as often to supply the body with its need for oxygenated blood. So this study fits with other studies suggesting poor cardiovascular health increases the risk of dementia. This makes sense since our brain, like all other organs in our body needs good blood flow to function. 

A second takeaway from this study is the impact of emotional stress on brain health. A higher resting pulse might mean your fight or flight response called the sympathetic nervous system is more often activated. This can be sign of emotional stress. There is evidence suggesting chronically elevated stress levels can increase the risk of dementia. One possible mechanism for this link is the effects of elevated levels of the hormone cortisol that is released with stress. High cortisol levels may have an adverse effect on the hippocampus, a structure in the brain that plays an important role with learning and memory.  

Here are my takeaways from this study. To protect your brain health:

1) Take steps to promote your cardiovascular health. Exercise regularly. Don’t smoke. Eat a Mediterranean style diet. Control cardiovascular disease risk factors such as elevated blood pressure, blood sugar, and cholesterol.

2) Take steps to control emotional stress. Make time to relax and have fun. Prioritize enriching time with friends and family. Consider stress-reducing activities such as yoga or meditation. Give yourself a chance for 8 hours of sleep every night. Avoid committing to more than you can reasonably handle.

Here is a link to the study:

https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.12495

 
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Posted by on January 2, 2022 in Uncategorized

 

Omicron Update

01 Jan

While on call for my clinic over Christmas, the Omicron variant’s extreme contagiousness became quite clear. I received call after call from vaccinated people who tested positive. This is what I’d been expecting as I’ve followed the story of omicron since learning of its existence on Thanksgiving. It is much more contagious than previous variants and our vaccines aren’t nearly as effective at preventing it from infecting us. At the same time, I’ve been heartened to see lower hospitalization rates than during previous waves in countries experiencing omicron surges. This seems to be from two factors. First, while vaccinations and previous COVID infections are not as effective at preventing omicron infections, they are decreasing the severity of infections. Even if our antibodies aren’t as effective at binding to Omicron’s spike protein, T cells induced by the vaccines are effectively neutralizing the virus. The second reason for lower hospitalization rates than during previous waves is that omicron appears to be less innately virulent. Multiple studies have shown it binds less effectively to lung cells, decreasing its ability to cause the devastating COVID pneumonia that has caused so much disability and death. 


But even if omicron isn’t causing as severe of disease, its extreme contagiousness is still straining health care systems and other essential institutions. A small percentage of a very big number is still big. That is to say, even if a small percentage of people with omicron need to be hospitalized, with so many folks infected, hospitalizations could still rise to concerning levels. Beyond that, a huge number of people getting sick all at once and out of work threatens the functioning of key institutions such as health care, schools, grocery stores, and public transportation. This is part of the reason the CDC shorted the period in which someone should isolate after being infected. You should isolate from others for 5 days, then for the following 5 days always wear a mask when around others. The rationale is that most of the virus shedding occurs during the first 5 days and any further, smaller amount of shedding the following 5 days can be minimized by wearing a mask. 


Right now I am most concerned about the two groups of people who don’t have immune protection against omicron. The first are those who haven’t been vaccinated or previously infected. The second are immunosuppressed people like organ transplant recipients who didn’t develop a protective immune response to vaccines. These groups could fill hospitals since right now we lack for available meds to reduce hospitalization. For much of the pandemic, monoclonal antibodies have been very effective treatments to prevent high risk people from being hospitalized or dying. But available monoclonal antibodies don’t work against omicron. The monoclonal antibody that does work against omicron is in very short supply. The Pfizer pill Paxlovid that reduces hospitalization and death by 89% is also currently so scarce as to be effectively unavailable. (The Merck med which lowers risk of hospitalization by only 30% is also scarce and difficult to access).


After we get through this omicron wave, there’s a case to be made that it will put us in a better place with COVID. Omicron appears to be crowding out delta to become the dominant variant. A less virulent variant of COVID will in the long term result in less disability and death. In addition, Omicron’s extreme contagiousness means many more people will have been infected, providing them with immunity for at least some period of time. 


Since there’s a good chance you or somebody in your household will be infected with COVID sometime soon, what is my advice? I’d first place yourself on a risk spectrum. On the one end, are people who are young, vaccinated, aren’t immunosuppressed, lack high risk health conditions, and won’t be spending time with people who are high risk of getting sick with Omicron. Such people are at low risk of directly hurting themselves or others by getting infected with COVID. The biggest harm from their getting infected right now is helping to overwhelm urgent care and primary care clinics should they seek care for COVID. They might also contribute to a chain of infection that could ultimately infect a high risk person. Finally, there is the risk that they might develop the poorly understood condition called “long COVID”, in which people feel and function poorly for some period of time after infection. With all that in mind, however, I’d say this group of folks can most safely open us their lives. At the other end of the spectrum are unvaccinated people, immunosuppressed people, and those who will regularly be around immunosuppressed people. These are the folks at highest risk of being or contributing to hospitalization and death. I recommend this cohort of people markedly decrease their physical interactions with others for roughly the next month. If around others, I recommend they be outside at a distance and if indoors, wear a high quality mask such as a KN95. By being careful over the next month, they’ll give time for case numbers to come down and the Pfizer med and the effective monoclonal antibody to become available. 


So what should you do if you get infected? If you’re at the low end of the risk spectrum, monitor you pulse oximetry. If it stays below 94%, make an apt with your primary care physician’s office or an urgent care clinic. If your oxygen level level is above 94% and you’re not having any severe symptoms such as marked shortness of breath, don’t seek medical care. Doctors won’t have any tools that will alter your clinic course since you will most likely recover without any medical treatment. Your seeking care will needlessly overwhelm already overwhelmed primary care and urgent care clinics. Allow them to focus their limited resources on higher risk people. Use over the counter treatments for cough and congestion such as a Flonase, a saline rinse, and Mucinex. Use Tylenol, Advil, or Aleve as needed for headaches, body aches, and fever.


If you are at the high end of the risk spectrum and get infected, immediately seek care your primary care clinic or an urgent care center. Make sure to to have your pulse oximeter readings ready. Your doctor may prescribe a med called Fluvoxamine as well as an inhaled steroid such as Budesonide.  Both have modest evidence for decreasing the risk of hospitalization and shortening duration of symptoms. (Note that some people develop nausea in response to Fluvoxamine and inhaled steroids can be expensive.) If you are very high risk, your doctor might try to obtain some of the very scare supply of Paxlovid or the effective monoclonal antibody called Sotrovimab. Be aware that your doctor has limited control over accessibility of these meds. 


This is a difficult time for us all. So let’s show each other some grace and patience in the early days of the new year. We will get through this.
 
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Posted by on January 1, 2022 in Uncategorized

 
 
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