Thursday, June 2, 2016

The Lyme brain and nootropics

Cognitive impairment is one of the most disabling symptoms seen in patients with Lyme disease.  The symptoms can be quite subjective. The symptoms can be very disconcerting and at times disabling. The complaint is almost universally overlooked by general physicians and neurologist. After all, there is no evidence of dementia.  Many patients will pass neurocognitive testing, rarely offered and quite expensive. SPECT scans, infrequently performed, may or may not be abnormal and when abnormal brushed off as nonspecific. But as a patient recently shared with me, before Lyme she performed great at a high level job requiring timely completion of complex intellectual tasks; she can still get the job done but it takes 3 times as long. On this basis it is no longer financially viable for her to continue the consulting work and she is applying for disability. Doctors tell their patients: its normal to be a little slower after 50, it is natural for math skills to slip a bit.  Increased difficulty with word retrieval is par for the course with middle age.  Maybe to some extent this is true, but Lyme patients experience something qualitatively – and quantitatively different.  Mainstream medicine with its black and white world view is deaf and blind to the complaints of Lyme sufferers who may: get lost, confused, space out and put their cell phones in the fridge. If it is not Alzheimer’s disease, frontotemporal dementia, Lewy body disease, a brain tumor, a subdural hematoma, hydrocephalus, a prion disease or a few other conditions patient are told there is nothing to worry about. We know differently.  Of course the same Lyme patients complaining of brain fog also complain of fatigue. Frequently the two are intimately connected and it is hard to separate cognitive issues related to fatigue from those that exist independently. The question then is: what, if anything can be done? 
Clearly if we are dealing with germs in the brain we need to use antimicrobial agents which are powerful, able to penetrate into the brain and able to target the specific organisms of concern.  Typically, the focus is on spirochetes, pleomorphic variants, blood parasites, bacteria in blood vessels, biofilms and perhaps other organisms, like worms.

What else?  How do we make the brain work better?

Drugs that make the brain work better are called nootropics. The best known are stimulants.  Drugs like Provigil help with wakefulness. Clearly treating fatigue may help. Drugs like Ritalin, Adderall help with focus, attention and task performance. These drugs impact the neurotransmitter dopamine and are particularly active in the frontal lobe, executive function area of the brain.

Drugs like Namenda, commonly used in Alzheimer’s disease, negate excessive activity of the neurotransmitter glutamic acid caused by brain inflammation and related neurotoxins. Patients on this drug frequently find they are able to think more clearly.
Cholinergic drugs promote the activity of acetylcholine, a neurotransmitter involved with memory and other cognitive functions.  Rather than a prescription drug, I have found the supplement Procera (or similar) to positively impact cognition.

Do bile acid binders, cholestyramine and Welchol help?  In some patients the answer seems to be yes. I am not sure why.  Toxins?  I don’t think so. The prototypic neurotoxin, QUIN does not cross the blood brain barrier well, hence the use of drugs like Namenda. However, bile acids and cholesterol, both of which are lowered with bile acid sequestrants have signaling effects in the brain.

Glutathione may help, but only IV.  It may reduce the burden of free radicles, reactive species causing oxidative stress, negatively impacting function of neurons. In addition, mitochondrial dysfunction is directly connected to oxidative stress. Alleviated the latter promotes function of the former. Mitochondria in brain cells are essential for the production of energy.
Ketone bodies?  Some patients experience incredible improvements on an Atkins like diet. A ketogenic diet changes the brains fuel from primarily to glucose to primarily ketone bodies. This may result in neuroprotection, decreased brain inflammation, decreased oxidative stress and better mitochondria function.  Perhaps ketone supplements help as well.

Hyperbaric oxygen therapy.  For practical reasons most patients only have access to home units with offer a low pressure. A new unit can be purchased for as little as 5500 dollars. Patients who do the best spend 2 hours or more per day in the chamber. The treatment reduces oxidative stress, promotes glutathione and has been specifically shown to improve neuroplasticity with reversal of abnormal SPECT scan patterns.

Food for thought

( Nothing here should be construed as specific medical advice)