Alzheimer’s disease is among the most feared diagnoses, with treatments that may slow early decline but don’t stop the disease. But there’s growing evidence that people could be taking steps to keep their brains healthy and reduce their risk of dementia.

Dr. Majid Fotuhi, an adjunct professor of neuroscience at Johns Hopkins and the author of a new book on brain health called “The Invincible Brain” believes Alzheimer’s can be prevented and that some cognitive degeneration can be reversed.

“I’ve been talking about preventing Alzheimer’s disease for more than 20 years,” he told Deseret News, noting his first book came out in 2002. “I want people to know that they play an important role in whether their brain stays healthy or whether it decays. And the other thing that’s very important to know is that just because you have family members with Alzheimer’s disease, it does not mean you will develop it.

“It means that you can use that as a call to action and be more proactive about taking care of your brain.”

Perhaps those considered most at risk of developing Alzheimer’s are people with one or two copies of the apolipoprotein E4 allele, which is a known risk factor for Alzheimer’s, greatly increasing the likelihood of developing the disease.

Fotuhi said even people with APOE4, as it’s commonly called, who have an active lifestyle and exercise regularly have lower levels of Alzheimer’s amyloid proteins in their brain. “In other words, exercise appears to negate the impact of the APOE4 gene on the brain,” he said.

Making your own difference

Fotuhi notes there’s “no one magic exercise” that’s most effective and experts debate whether aerobic exercise is better than weight training, or vice versa.

“In general, I recommend that people do a combination and that’s what I do myself,” he said. “I usually do 45 minutes to an hour of cycling and then I do 30 to 40 minutes of weight training three times a week — and if I have time, maybe a fourth day.”

The key is improving your fitness, which he measures with basic questions: Can you walk three miles easily? Can you go up 10 flights of stairs? Nor is it a matter of being fit compared to same-age peers, he notes, because the average person these days is not fit. He suggests being fit compared to someone 20 years younger than you are.

It’s never too late, he adds, noting he’s watched older patients get physically healthier and sharper mentally.

“I had many patients who were in their 70s and even early 80s who improved. And our brain does not stop growing; it doesn’t stop changing just because we get older. Plus, related to this topic is a paper that was published recently in Nature. They found that individuals who are in their 70s and early 80s do have neurogenesis in their hippocampus,” he said.

“Neurogenesis means the growth of new neurons, and hippocampus is a thumb-sized brain structure that’s critical for learning and memory. With aging, usually the hippocampus shrinks, and when it shrinks a lot, people develop Alzheimer’s disease symptoms.”

According to the research paper Fotuhi cited, neurogenesis doesn’t stop as people age, but less occurs for those with Alzheimer’s. He also noted that in those with the disease, the new cells don’t mature normally. But exercise increases the brain-derived neurotrophic factor that’s needed for cells to mature. Boosting that helps with both generation of new neurons and their maturation, he said.

Brain ‘super agers’

Brain “super agers” — people in their 80s and older with brain function comparable to folks 20 or 30 years younger — have both more neurons and their neurons mature, per Fotuhi.

“This study shows that whether or not you have Alzheimer’s disease has to do with are you making enough new neurons and whether these new neurons are being matured. If you don’t have enough new neurons and if the neurons are not mature, you get Alzheimer’s disease. If you have plenty and they’re very mature, you become a ‘super-ager,’ and if you’re in between, you become an average aging adult,” Fotuhi said.

It’s not just a matter of preventing damage, though that’s crucial, he said. He’s adamant that some damage can be reversed. Alzheimer’s has stages and the first signs are often mild cognitive impairment, which in some people never progresses to actual Alzheimer’s. He said early brain changes can be reversed.

“I have seen it firsthand in thousands of patients — not dozens or hundreds — thousands of patients in the past 20 years. You can reverse the effects of aging on the brain.”

Embracing 5 pillars of brain health

He tells the story of a patient named Carol whose sister brought her to the doctor appointment because she was forgetful. The sister said Carol watched TV all day, sitting vapidly in front of the screen, something she’d done for well over a year. The sister wanted a diagnosis of Alzheimer’s so she could get power of attorney, sell Carol’s house and use the money to pay for Carol’s long-term care, Fotuhi said.

He described Carol as well-dressed and quiet, but someone who engaged only minimally, answering questions with a word or two. Is something bothering you? “No.” Why are you here? “I don’t know.”

Carol, it turned out, had medical conditions, including sleep apnea, diabetes and depression. Some of her medications were sedating. So he opted to tackle the medical problems first, focusing on changes that could increase neurogenesis.

“She gradually woke up, literally,” he said. “She started walking five minutes a day and then 10 minutes a day. By six weeks in the program, she was walking almost normally and she was interacting with our brain coaches and she was getting brain training.”

She was working on what he called the five pillars of brain health:

• Stress reduction/meditation

Those five things were the recipe he used to bring Carol back. “She was funny, she had multiple hobbies, she actually started looking for a job.” He could also untangle her downward spiral: Pain medications sedated her and because of that, she was sitting all day and became depressed and stopped caring for herself and gradually she declined.

Nor was it just a theory. Fotuhi and colleagues published results for multiple patients in the Journal of Prevention of Alzheimer’s Disease, using MRIs that looked at the size of the hippocampus before and after treatment targeting those five pillars.

Hippocampus size begins to shrink a little starting around age 50 as a normal part of aging. But in those who exercise, sleep, eat well, reduce stress and do brain training, the hippocampus grew modestly, Fotuhi’s research found.

“To be fair, Carol was our best patient,” he said, noting someone with severe cognitive decline and confusion is not likely to return to full function, though they can improve. “The earlier you intervene, the better it is,” he said.

The results were so clear on brain MRIs, he said, that the radiologist reading them sent his own mother to Fotuhi for the 12-week program.

Brain-friendly habits

The brain is big, Fotuhi noted, and different parts form networks. He recommends people work on parts of their brain they hope to improve. Take lessons in what you want to be better at, he said.

“When you take lessons and you’re learning something new, you’re working on different networks in the cortex and hippocampus. In other words, there is no one game that you will do which will then improve your brain functions so that you won’t get Alzheimer’s disease. You need to tone up your brain just like you can tone up your body parts. And just like you could say, “OK, I’ll just work on my biceps and triceps,” or “I want to work on my quads,” or “I want to work on my core,” you could just do the same thing with your brain.”

One of the keys is picking things you enjoy, because you’re more likely to stick with them, he said. Learning something new is great, because you activate different parts of your brain. “Every time you learn something new, you stimulate your brain,” he said.

Over the years, he’s learned different languages; right now Fotuhi is fine-tuning French because his book is being translated into French. When his kids visit from college, they do quick card games and he’s proud when he manages to win because “those kids are so sharp and so quick it’s hard to keep up with them.”

Variety is good. So is consistency. He wants people to incorporate brain-strengthening into their routines, making it as normal a habit as brushing your teeth. He keeps exercise, sleep, nutrition, stress reduction and brain training in the back of his mind daily and lets those needs help drive his decisions. That way, when he chooses food, for example, he doesn’t choose junk food.

He has an odd stress meter: “I think, is this thing worth ruining my hippocampus over?”

Probably not, so he doesn’t stress much. “I try to stay calm because I appreciate that everything is fixable, everything is manageable.” You can’t avoid all stress, he said, but he is dedicated to keeping it down.

“I have a good understanding of all the things that are good for my brain and I just do them out of habit,” he said. “My suggestion is for everyone to sort of realize what the five pillars of brain health are and make those a part of their daily routine so that they don’t have to think about it.”

Looking forward

Fotuhi predicts that in five to 10 years Alzheimer’s will be treated like diabetes. Type 2 diabetes is a condition that in most cases can be prevented, he said. And those who do start to develop it can do things that help walk it back, through medication and reducing risk factors, such as changing eating habits.

“The same will apply to Alzheimer’s disease. You will have plenty of opportunities to prevent Alzheimer’s disease. If you are in the in-between condition called mild cognitive impairment, you definitely have the opportunity to slow the rate of decline and reverse cognitive decline and actually become one notch sharper. And if you do have early stages of Alzheimer’s disease, you can still get one notch better. The worse you are, the less likely it is that you’ll be the same as you were 30 years earlier. You’ll be as good as like four years earlier, but not 30 years.”

When the disease is severe, it can’t be walked back. So prevention, he said, is key.