Wednesday, May 31, 2017

A Home for Brain Care: Institute Empowers People to Take Charge of Brain Health

patient and doctor

Elizabeth has a strong family history of Alzheimer Disease going back two generations. As she nears the age her father was when he showed symptoms, she is still healthy but worries about her future. Brandon is a young man whose mother has mental illness, and he’s concerned about feeling slightly depressed. James comes to see his doctor with the results of genetic tests suggesting a heightened risk of stroke, or Parkinson’s disease. Traditionally, neurologists and psychiatrists, who specialize in the brain, only care for patients with disease. But Elizabeth, Brandon, and James do not have diseases.  What can we do for them?

At the Mass General Institute for Brain Health, experts from across the neurosciences are joining together to answer that question. For people whose risk for brain disease is elevated, or who simply want to do everything they can to preserve and enhance their brain health as they age, the Institute brings clinicians, researchers and patients together in a multidisciplinary effort to optimize brain health across the life span. Geared towards prevention, the Institute provides precision risk assessment and individualized care for people at high risk for brain disease, or for anyone interested in preserving and promoting good brain function as they age.

What does a visit to the Institute entail? After an initial telephone screen and evaluation by questionnaire, an individual coming to the Institute will undergo a comprehensive evaluation by a physician whose particular specialty (neurology, psychiatry or physical medicine and rehabilitation) is matched to the individual's concerns. This first visit includes a review of medical records, a complete history, and a brief physical assessment. Through this process, the individual and their team develop a comprehensive plan for maintaining and enhancing brain health, including goals and a set of next steps. These can include advice about how to limit the impact of concurrent medical conditions on the brain, sophisticated lifestyle coaching, including guidance on diet, exercise and stress reduction, meditation and mindfulness practice, and sleep. People may also be referred for further genetic testing, or other types of testing as indicated. Through the Institute, individuals gain access to all of the clinical neurosciences at Mass General, including any clinical trials currently underway to reduce the risk of brain disease, as well as therapists, nutritionists, psychologists, and providers at the Benson-Henry Institute for Mind Body Medicine.

Crucially, individuals are followed in the months and years after their initial visit. This helps in forming a life-long partnership with the Institute to support the establishment of brain healthy habits and to provide guidance when new illnesses develop that can impact the brain. The unique longitudinal approach offers people a “home for brain care,” says Jonathan Rosand, MD, Institute Co-Director, Chief, Division of Neurocritical Care and Emergency Neurology and an Investigator in the Center for Genomic Medicine. “We want to stay in touch with people over their lives, to help them develop the best habits possible to maintain brain health, and make sure they have rapid access to the latest discoveries and treatments as they become available.”

That longitudinal approach also provides an unparalleled opportunity for research, explains Institute Co-Director Rudolph Tanzi, PhD. “As the cornerstone of the Institute’s investigations, we are creating a large cohort of subjects whom we will track as they age,” says Tanzi, who is Vice-Chair of Neurology, Director of the Genetics and Aging Research Unit at MassGeneral, and a path-breaking geneticist and neuroscientist who specializes in Alzheimer disease. He and Rosand are currently looking at how lifestyle interventions—diet, exercise, sleep and stress reduction—change the body and may boost brain health.

Rosand’s interest in prevention was sparked by his research in genetics and his experience with patients with stroke, traumatic brain injury and encephalitis in his ICU. “As more and more risk genes for brain diseases are being discovered, and more and more people are learning they are at risk for brain disease, I am increasingly approached by disease-free individuals who have learned of their elevated risk and want to do whatever they can to reduce their risk,” Rosand says. And among his ICU patients, he noticed that survivors of brain injuries often developed anxiety, depression, and posttraumatic stress as they recovered. And it wasn’t only the patients—their family members and caregivers show a similar increased risk for these brain disorders.

To try to lower that risk, Rosand enlisted psychologist Ana-Maria Vranceanu, PhD, of the Behavioral Medicine program in the Department of Psychiatry, who developed a program, Recovering Together, to teach patients and their families breathing, mindfulness and self-care skills early in the recovery process. The training starts in the hospital, and continues after discharge via TeleHealth secure live video. By providing early skills training and keeping tabs on patients and at-risk caregivers after they leave the ICU, Vranceanu and Rosand have a chance to prevent chronic anxiety, depression and PTSD before they ever develop.
 
The Institute also serves to triage referrals into existing Mass General programs that can best help individuals seeking help. For example, for young people at risk for mental illness, Daphne Holt, MD, PhD, offers the Resilience Enhancement and Prevention Program (REPP) in the Department of Psychiatry. Many risk factors are well known, says Holt: Having a first degree relative with mental illness, traumatic life experiences, or the presence of mild symptoms all increase the chances of an individual developing a serious psychiatric condition. At the REPP, at-risk young people receive a comprehensive evaluation, and opportunities to develop better coping skills related to mindfulness and positive psychology, and improve social connections—“things we believe help people develop resilience in the face of adversity,” says Holt. Whether imparting those skills helps stave off mental illness remains to be seen—Holt is now running a clinical trial of at-risk college students to begin to answer that question. 

Holt, Vranceanu and other researchers at the Institute want to bring prevention for brain diseases on par with other fields “If you had a first degree relative who had breast cancer, would you take precautions to reduce your risk? Would you get mammograms earlier, or ask for genetic testing?” asks Holt. “Of course you would, because that's what your doctor would recommend.” In the case of brain disease, physicians are more on the frontier, Holt says. “Even though we know about many risk factors, we still have to develop recommendations or interventions and prove they reduce people’s risk.”

That’s why research is a key aspect of the Institute’s mission. Patients at the Institute have the opportunity to participate in ongoing research and receive the interventions they provide. Research areas include genetic assessment of risk for brain disease, neuroimaging studies of normal and pathological brain function and aging, brain stimulation technologies to modulate and maximize cognition, behavior and emotion, and mind-body treatments to reduce stress and related conditions.

“There is not a whole lot known about the effect of lifestyle interventions on brain aging,” says Tanzi.  “Our goal is to apply hard-core rigorous science to analyze the efficacy of lifestyle or pharmaceutical interventions, to find out what works, and why.  We want to take the subjective ‘new age’ factor out of mind-body interventions.”

Recently, Tanzi and his colleagues reported their work showing that a brief course of meditation leads to changes in metabolism and gene expression in healthy volunteers. Some of the changes affect inflammatory networks in ways that could help fight of Alzheimer’s and maintain brain health. Tanzi is also interested in alterative medicines, like nutritional supplements and over-the-counter products. He is using his unique cell-based model of Alzheimer’s pathology to study the biological effects of these popular products.

To be clear, while healthy lifestyle choices have many benefits, there are no specific exercise, diet or other regimens that have been proven to prevent Alzheimer’s or any other brain diseases. However, MassGeneral boasts a deep bench of researchers working to understand more about aging and loss of brain function and develop preventive strategies. Bradford Dickerson, MD, Director of the Frontotemporal Disorders Unit in the Department of Neurology, specializes in studying aging, memory and dementia. Dickerson analyzes “super agers,” people who reach their reach their 80’s and 90’s with their memory intact. According to his work, these elders have brains that look like, and function like, those of much younger people. In specific areas related to learning and memory, the super agers show much less loss of brain volume over time, compared to normally aging people. The ongoing work provides clues as to the nature of brain aging, and could lead to specific and personalized preventive strategies in the future.

The Institute sees patients and visitors on the eighth floor of the Wang building on the Mass General main campus in Boston. For appointments, please visit www.massgeneral.org/brain-health, or call 617-726-4881.

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