A while back, I wrote an article on cerebral small vessel disease, a very common condition in which the small blood vessels of the brain develop signs of damage.
If you’re an older adult and you’ve had an MRI done of your brain, chances are pretty good that your scan showed signs of at least mild signs of this condition; one study of older adults aged 60-90 found that 95% of them showed signs of these changes.
These are basically like teensy strokes in the brain. Most are un-noticeable to people, but if you have enough of them, you can certainly develop symptoms, such as cognitive impairment, balance problems, or even vascular dementia.
To date, the cerebral small vessel disease article has generated over 100 comments and questions from readers. A common theme was this: “My MRI shows signs of this condition. What can I do?”
As I explain in the article and the comments, the first thing to do is to work closely with your doctors to understand what is the likely cause of the damage to the brain’s small blood vessels.
Now, when you do this, you may well find that your doctor just shrugs, or waves off the question.
That’s because in most people, cerebral small vessel disease is thought to be in large part a result of atherosclerosis (more on this term below) affecting the smaller arteries of the brain. And atherosclerosis affects just about everyone as they age, because it’s related to many basic cardiovascular risk factors that become very common in late-life.
So in many cases, asking the doctor why you have signs of cerebral small vessel disease may be like asking why you might have high blood pressure, or arthritis. These are common conditions and they are usually due to medically mundane causes and risk factors, including sub-optimal “lifestyle” behaviors and the general “wear and tear” on the body that is associated with aging.
(However, in some people, damage to the small vessels in the brain may be related to one or more particular medical conditions. Younger people, in particular, seem more likely to have a particular condition or risk factor that may be causing most of the damage.)
Whether you are younger (i.e under age 60) or older, always start by asking your doctors what they think are the most likely causes for any cerebral small vessel disease, and what they recommend you do to slow the progression.
And for most people, the main advice will be this: evaluate and address your cardiovascular risk factors.
“Vascular,” as you probably already know, means “blood vessels.” And blood vessels are critical to the function of every part of the body, because blood vessels are what brings oxygen and nutrients to every cell in the body. They also carry away waste products and toxins. So, blood vessel health is key to brain health.
This article will help you better understand how to address blood vessel health. Specifically, I’ll cover:
- Understanding cardiovascular risk factors
- 3 key ways blood vessels become damaged
- What is atherosclerosis
- Why some chronic conditions are considered risk factors
- The number one risk factor for future cardiovascular events
- 12 key cardiovascular risk factors
- How to manage cardiovascular risk factors for better brain health
- 5 key approaches most older adults should implement
Note: Experts who study cerebral small vessel disease believe the story of what might be causing it is more complicated. That said, identifying and managing one’s cardiovascular risk factors is currently the mainstay of treatment and is likely to remain so. If you want to learn more about causes and contributors to cerebral small vessel disease, see here: Cardiovascular risk factors and small vessel disease of the brain: Blood pressure, white matter lesions, and functional decline in older persons.
Understanding Cardiovascular Risk Factors Known to Affect Brain Health
Lots of factors affect the health and function of your blood vessels. Before we dive into specific factors, let me share some practical ways to think about these risk factors.
3 key ways blood vessels become damaged
Generally, what is bad for blood vessels will fall into one of the following three categories:
- A form of inflammation: “Inflammation” basically means that aspects of the body’s immune system are revved up. In the short-term, this helps fight infections, but in the longer-term, this actually creates a fair amount of wear and tear on cells in the body. Inflammation can also cause the blood vessels to build up plaque.
- Inflammation is manifested in the body in many different ways. These include having higher levels of certain proteins, such as C-reactive protein, and/or by the increased presence of certain types of white blood cells.
- Many health conditions, including obesity, are associated with chronic inflammation in the body. Aging is also associated with chronic inflammation, a phenomenon sometimes called “inflammaging.”
- For more, see What is Inflammation?
- A form of mechanical stress: This means physical forces — such as higher blood pressure — that create wear and tear on blood vessels.
- A form of mechanical obstruction: This means build-up on blood vessel walls (sometimes called “plaques”) or blockages of blood vessels. A narrower blood vessel cannot transport oxygen, nutrients, or waste products as effectively as before. Plaques can also break off and then block a downstream part of the blood vessel; this can cause strokes or heart attacks.
Some risk factors will fall into more than one category.
What is atherosclerosis?
Atherosclerosis (and its related term, arteriosclerosis) means the process of artery walls becoming inflamed, thickened (by plaques), and then hardened. Calcium is often deposited into the blood vessel wall, which contributes to stiffening and “calcification.” This process of accumulating damage happens over years and years, and is influenced by lifestyle factors, medical conditions, and other health factors.
In short, atherosclerosis is the most common way that blood vessels become slowly damaged and obstructed over time, and this process happens in large part due to chronic exposure to inflammation and mechanical stress.
Hardened arteries will contribute to higher blood pressure. Having a lot of atherosclerosis is also understandably a strong risk factor for developing problems related to blood vessels, such as heart attacks and strokes.
Damaged blood vessels also tend to become less resilient, and so they are also more prone to break or burst. Such breakages can be the underlying cause of ruptured aneurysms and certain forms of stroke.
Why some chronic health conditions are considered cardiovascular risk factors
Certain health conditions are considered cardiovascular risk factors, because research has shown that they are associated with a higher chance of having or developing cardiovascular disease. They can be categorized into two types:
- Health conditions that cause inflammation or other stress on blood vessels:
- Lots of diseases fall into this category, including diabetes and most auto-immune diseases.
- Mental health conditions such as depression or anxiety may also qualify, as these are associated with increased stress levels in the body.
- Health conditions that are often caused by damage to blood vessels.
- This includes chronic kidney disease, which often — but not always — is related to blood vessel health, as well as peripheral artery disease.
The Number One Risk Factor for Future Cardiovascular Events
Probably the top risk factor having a cardiovascular event is having had one in the past.
This is called having “established cardiovascular disease,” or “clinical atherosclerotic cardiovascular disease.” It means a person has already experienced a health event or significant condition related to atherosclerosis. These include:
- Heart attacks (“myocardial infarctions”), especially those related to a blockage in the coronary arteries, which supply blood to the heart
- Strokes, which happen when blood flow to the brain is blocked
- Peripheral artery disease, which happens when large arteries bringing blood to limbs (or sometimes organs) develop significant blockages
Since people with established cardiovascular disease have a higher risk of future cardiovascular events, clinicians are usually more proactive about treating their risk factors, to prevent future events. This is called “secondary prevention.” (“Primary prevention” means treating risk factors in people who have not yet had an event.)
The Rotterdam Study, among others, has found that a history of stroke or heart attack is associated with more signs of cerebral small vessel disease on MRI.
12 Key Cardiovascular Risk Factors that Affect Brain Health
Now that we’ve covered the broader categories of what affects blood vessel health, below is a list of the most common and important specific risk factors. If you’ve been worried about cerebral small vessel disease, these are probably the risk factors you’ll want to be discussing with your doctors.
This list is based in large part on the Uptodate.com chapter on established cardiovascular risk factors.
12 key cardiovascular risk factors
- High blood pressure
- High cholesterol, especially high low-density lipoprotein cholesterol (LDL-C) and high triglycerides
- Problems managing blood sugar, including diabetes, insulin resistance, and impaired glucose tolerance
- Chronic kidney disease (defined as an estimated glomerular filtration rate (eGFR) < 60 ml/minute)
- Obesity
- Cigarette smoking
- High levels of inflammation (as measured by C-reactive protein or other tests)
- Obstructive sleep apnea
- Psychological stressors (including depression, anger, anxiety, and stress)
- Insufficient exercise
- Dietary factors, including
- Diets with a high glycemic index or load
- Insufficient fruit and vegetable intake
- Insufficient dietary fiber
- Higher intake of red meat and high-fat dairy products
- Age and gender
Understanding the 12 cardiovascular risk factors in more detail
Now, you may be wondering: how are each of these risk factors defined? What blood pressure is high, or “too high”? What constitutes “insufficient exercise”?
This is where things get tricky. Basically, almost all of these risk factors can be thought of as a risk spectrum, with one side indicating increased cardiovascular risk and the other side associated with less risk. (Although for some factors, extremes on either side are associated with risk).
Where exactly to place a numerical cut-off, for the purpose of defining a disease — e.g. defining “hypertension” — tends to be hotly debated by experts. Similarly, there is often debate as to what constitutes an “optimal range,” or “optimal intake” (for diet and exercise factors), in terms of minimizing cardiovascular risk.
Within this article, it’s not possible to present each factor in depth. Still, here’s a more detailed version of the list with some practical information for each, along with some relevant resources.
Then in the next section, I’ll cover five key approaches, which can address many cardiovascular risk factors simultaneously.
12 Cardiovascular (CV) Risk Factors (more detailed)
- Blood pressure:
- Higher is generally riskier, lower generally corresponds to lower CV risk.
- Treatment of high blood pressure has been associated with a reduction in CV risk.
- For more information: New High Blood Pressure Guidelines Again
- Cholesterol (also known as “lipids”)
- In general, higher levels of total cholesterol, LDL cholesterol, and/or triglycerides have been associated with higher CV risk.
- Recent guidelines on lipid-lowering recommend basing treatment on a person’s 10-year risk of cardiovascular disease, rather than solely focusing on aiming to get cholesterol below a specific number.
- The recent guidelines also recommend indefinite treatment with a statin drug for all people with proven clinical “atherosclerotic cardiovascular disease.”
- Randomized trials find that treatment of elevated cholesterol (with statins) does reduce CV risk in many people.
- Research also finds that cholesterol levels can be lowered through lifestyle modifications (e.g. changes to diet, weight, and physical activity).
- Blood glucose (blood sugar) and insulin levels
- Higher levels of blood sugar — which usually indicates pre-diabetes or diabetes — are associated with higher CV risk.
- Elevated blood sugar after meals has been associated with increased CV risk, and may be an important risk factor in of itself.
- Controlling blood sugar in people with diabetes has been shown to reduce CV risk.
- That said, studies find that reducing blood sugar too much via medication is also associated with increased cardiovascular risk (see here and here).
- Research suggests that a hemoglobin A1C of 7-7.5% may be safer than using glucose-lowering medications to get the hemoglobin A1C below 7.
- People with diabetes should avoid frequent hypoglycemia.
- Insulin is a hormone that enables the body’s cell to absorb and use glucose. Higher insulin levels are associated with insulin resistance and pre-diabetes. For more information: Prediabetes & Insulin Resistance.
- Kidney function
- Chronic kidney disease (usually defined as having an estimated glomerular filtration rate that is chronically less than 60mL/minute) has been associated with increased risk of CV disease.
- A glomerular filtration rate of 90-120 mL/minute is normal, and a rate of 60-90 mL/minute is usually considered mild loss of kidney function.
- For more on chronic kidney disease, including how to diagnose and manage it: What Is Chronic Kidney Disease?
- For more on addressing CV risk factors: Cardiovascular Disease in CKD
- Obesity
- A higher body-mass index (BMI) has generally been correlated with a higher risk CV disease, as in this study.
- Obesity increases the likelihood of developing other conditions that increase CV risk, including high blood pressure, high cholesterol, insulin resistance, and diabetes.
- Being overweight does seem to become less risky as one ages; learn more about the “obesity paradox” here and here. Some experts also believe that waist circumference is a more useful measurement than BMI in older people.
- Tobacco smoking (and other forms of inhaling toxins)
- Smoking cigarettes is a well-established and strong risk factor for CV disease. The CDC estimates that smoking causes one in three deaths from cardiovascular disease.
- Second-hand smoke exposure is also associated with CV risk.
- Smoking is also known to particularly cause damage and inflammation to blood vessels.
- Research finds that quitting at any age helps people live longer.
- Inflammation (as measured by C-reactive protein or other tests)
- C-reactive protein C-reactive protein is synthesized by the liver and is considered a good marker of inflammation in the body.
- Higher levels of C-reactive protein can be caused by a variety of specific health conditions. They may also reflect more generalized chronic inflammation in the body.
- Research has found that C-reactive protein levels often correlate with the degree of existing atherosclerosis in a person’s blood vessels, and also with the risk of future CV events.
- Statins have been shown to lower C-reactive protein levels, independent of their effect on LDL cholesterol levels. This may be part of the way that statins reduce the risk of CV events.
- Using C-reactive protein to screen people without symptoms of CV disease is controversial, mainly because it’s unclear that this improves outcomes (compared to using the risk factors included in a “traditional” cardiovascular risk calculator.)
- Obstructive sleep apnea
- Obstructive sleep apnea (OSA) is a common sleep-related breathing disorder
- People with OSA have a higher risk of experiencing CV events.
- Treatment of OSA has been associated with improvement in high blood pressure and some other cardiovascular factors. However, a recent meta-analysis found that OSA treatment with positive airway pressure did not result in fewer CV events.
- Psychological stressors
- Research has linked psychological conditions, including depression, anxiety, and chronic stress, to CV risk.
- A randomized study found that stress-management training was associated with improved markers of CV risk, in people with pre-existing heart disease. Another study found that depression treatment reduce the risk of a first CV event.
- Exercise and physical activity levels
- Generally, greater amounts of exercise and regular physical activity correlate with decreased CV risk, as noted in this study.
- A recently published analysis of data from the LIFE randomized trial found that in a previously sedentary group aged 70-89, increased physical activity (as measured by a wearable device) did correspond to a lower risk of experiencing cardiovascular events.
- Guidelines generally recommend that people aim for 150 min/week of moderate aerobic physical activity, or 75 min/week of vigorous aerobic activity. However, research suggests that lesser amount of exercise also can provide benefit, so some exercise is always better than none. For a review of the effect of exercise on cardiovascular outcomes, see here.
- Dietary factors
- Research generally suggests that higher intakes of dietary fiber, fruits, and vegetables are associated with a lower risk of CV disease. Newer research suggests that the benefits of these foods is at least in part due to their impact on the gut microbiota (the “good bacteria” in every person’s gut).
- Research also suggests that a plant-based diet (one with no or minimal animal products, and minimal processed foods) can lead to significant reductions in CV risk.
- Red meat consumption has been associated with a higher risk of CV disease in some research, including this study.
- The risks and benefits of eating different types of fat or other animal products remain debated.
- Although many observational studies suggest that diets with a lower glycemic load are associated with lower CV risk, randomized trials have not always confirmed that such diets improve CV risk markers such as cholesterol or inflammation markers.
- A very interesting study published in 2015 found that individuals have very different blood sugar responses to the same meal. This suggests that low glycemic diets may be more effective for some people than for others.
- Age and gender
- CV risk generally goes up as people get older.
- CV risk factors affect both genders but may do so differently, depending on the factor.
How to manage cardiovascular risk factors for better brain health
Again, if you’ve become concerned because brain scans have shown signs of cerebral small vessel disease, your very first step should be to talk to your healthcare providers. Ask them what they think are the most likely causes of the brain changes that are visible on the scans.
No matter what they say, you’ll probably still want to review and address cardiovascular risk factors.
(A possible exception: it might not be worthwhile for a person who has become quite debilitated and whose goals of medical care are mostly prioritizing comfort, such as someone with advanced Alzheimer’s or another advanced illness. For more on goals of care, see this article.)
Now how should you do this? You might think that the answer is to work away to evaluate and treat each one of those factors.
That’s not necessarily a bad idea, but it can be quite labor-intensive. It also carries the risk of “falling down the rabbit hole,” since exactly how to treat some of these risk factors — such as cholesterol — is hotly debated by medical experts.
So instead of delving into the nitty-gritty and attempting to optimize each risk factor, I recommend starting by considering a handful of high-yield “better health” approaches. Studies generally find that these do correspond with lower cardiovascular risk.
5 better health approaches to help reduce cardiovascular risk
Below are my top recommendations. These are beneficial to most older adults. Check with your doctors to confirm that this approach is likely to benefit you or your older relative, or to troubleshoot any concerns or questions you might have.
- Avoid tobacco smoke.
- If you’re a smoker, stopping is one of the most powerful ways to reduce inflammation in your blood vessels, so get help quitting smoking.
- If you live with a smoker, see if you can persuade that person to stop, for their own health and for yours.
- Bonus benefits:
- Quitting smoking will improve lung function within days, and will reduce cancer risk. It will also save you money.
- For resources on helping older adults quit: Quitting Smoking for Older Adults.
- Get more exercise.
- Most older adults don’t currently get the recommended amount of exercise (150 min/wk of moderate exercise or 75 min/wk of vigorous exercise).
- It’s generally best to start by assessing one’s current level of exercise, and then making an effort to modestly increase one’s weekly exercise. A step-tracker is often very helpful.
- Trying to walk more is a good goal for many older adults.
- Sedentary older adults may benefit from enrolling in programs to help them exercise.
- If pain, shortness of breath, falls, or other problems are limiting one’s ability to walk or do other exercise, be sure to ask your health providers for help.
- Bonus benefits:
- Increased exercise has been associated with countless benefits, including maintenance of mobility, improved mood, better sleep, better brain function, and more.
- For more on exercise in later life, including the four types of exercise all older adults need, see: Go4Life from the National Institute on Aging.
- Eat a “healthier diet.”
- The exact components of a healthy diet can be debated, but the general principles as articulated by Michael Pollan are pretty sound: “Eat real food. Not too much. Mostly plants.” The components that I believe are most important include:
- Eat lots of vegetables, greens, fruits, whole grains, beans, and lentils.
- Such plant foods provide crucial fiber, vitamins, and minerals.
- Eating them has also been associated with a healthier microbiome (the good bacteria in the gut, which we are realizing play a key role in managing the immune system and inflammation).
- For vegetables, emphasize non-starchy ones (potatoes don’t count!) and try to include several different types, such as leafy greens, cruciferous vegetables (broccoli, cauliflower, etc), orange/red vegetables (carrots, beets).
- Minimize added sugars, fast food, and processed foods, including processed meats.
- Minimize simple starches (e.g. refined flour, most sweets), especially if your bloodwork suggests problems managing blood sugar.
- Eat lots of vegetables, greens, fruits, whole grains, beans, and lentils.
- Research has also suggested that intake of several specific types of foods may be beneficial to older adults. Some to consider include:
- Nuts and seeds (especially flaxseed)
- Foods containing polyphenols, which include olive oil and berries
- Cocoa and tea
- Fish, especially oily fish, which contains omega-3 fatty acids. (Randomized control trial data of fish oil supplements often does not find much effect, so supplements may not be as effective.)
- People with high blood pressure often benefit from a diet lower in sodium.
- Research suggests that a person’s response to diet is highly individual.
- Before persisting with a certain dietary plan, it may be good to ask your clinicians for help determining whether your body is responding well to a certain diet.
- Bonus benefits:
- A healthier diet often is associated with benefits beyond cardiovascular health. These may include improved mood, increased energy, easier weight loss, decreased constipation, and more.
- Diets proven to improve cardiovascular risk factors include the Mediterranean diet and the DASH (Dietary Approach to Stop Hypertension) diet. Learn more here:
- The exact components of a healthy diet can be debated, but the general principles as articulated by Michael Pollan are pretty sound: “Eat real food. Not too much. Mostly plants.” The components that I believe are most important include:
- Seek out and maintain social connections and purpose.
- Relationships, purpose, and feeling that one is contributing help older adults feel their best, and are also associated with better health outcomes.
- For those older adults who feel lonely, have few social connections, and/or feel they may not have enough purpose, options include:
- Making an effort to reconnect or improve connections with family and friends.
- Seeking work or volunteering opportunities.
- Signing up for an exercise class, educational activity, or other activity, whether designed for older adults or for the general public.
- Participating in activities at one’s local center for older adults.
- Considering relocation to a more supportive community or environment, if one is often physically isolated due to transportation issues or the location of one’s home.
- Joining a support group.
- Identifying a cause or project to work on.
- Participating in a local church or spiritual community.
- Be sure to talk to a doctor or other clinician, if physical or mental health symptoms are interfering with the ability to participate in activities.
- Mental health symptoms such as frequent sadness or lack of interest in things may be a sign of depression, and should be evaluated.
- Difficulties with memory or thinking should also be medically evaluated.
- Bonus benefits:
- Social connections and maintaining purpose are key factors in maintaining a sense of well-being in late-life.
- For more on addressing loneliness or social isolation, see the resources listed here: Addressing Loneliness in Aging.
- Use non-drug methods to manage stress, anxiety, and insomnia.
- Several different methods can be used to manage the mind and one’s mental state.
- It is often a good idea to use them in combination.
- Clinicians and other experts can help you determine which combination is best for whatever mind problem is most troublesome to you.
- Methods to consider include:
- Cognitive behavioral therapy, which has been shown to be effective to treat insomnia, stress, and anxiety issues, and also exists in online formats
- Mindfulness-based stress reduction
- Exercise
- Relaxation therapies
- Spiritual practices
- Activities that increase feelings of social connection and purpose
- Various forms of meditation
- Increased time outdoors and in nature
- Musical activities
- Skills and support programs, especially if one’s stress is related to caregiving, chronic illness, or another specific type of life challenge
- Various forms of psychotherapy
- Older adults with sleep problems should be properly evaluated for underlying medical problems, as these are common and may require treatment directed at these problems. For more, see 5 Top Causes of Sleep Problems in Aging, & Proven Ways to Treat Insomnia.
- Bonus benefits:
- Most of the methods above are generally associated with better overall well-being and health.
- Most medications — whether prescription or over-the-counter — used to treat anxiety, stress, or insomnia affect brain function and balance in older adults. Learning to manage these common problems without medication can reduce fall risk and help preserve brain function.
- Several different methods can be used to manage the mind and one’s mental state.
My bottom line on managing cardiovascular risk factors for better brain health
You’ve probably already noticed: my top five recommendations for addressing cardiovascular risk factors are all “healthy lifestyle” basics:
- Don’t smoke
- Get plenty of exercise
- Eat a healthier diet
- Seek out and maintain social connections and purpose
- Use non-drug methods to manage stress, anxiety, and insomnia
Most people are well aware of numbers 1, 2, 3, 4, and some have also heard of the various “lifestyle” approaches to managing stress and insomnia.
But far too few people are trying to put these in action. Which is a shame, because in many cases these approaches work as well as medications do. But they are better, because they bring on lots of bonus benefits. And they are safer, because they can enable older adults to manage cardiovascular risks and other aspects of health with fewer drugs.
See and care for the forest before getting too focused on the trees
As geriatricians, we always try to see and care for “the forest” before getting too focused on “the trees.”
Don’t make the mistake that many people make. Yes, you can try to tinker with each cardiovascular risk factor one at a time. And yes, there are plenty of health providers out there who will offer you lots of testing, and probably some prescription medications.
There is a certainly a role for such tests and medications. But before you go too far along that route, remember that it’s always worthwhile to start with healthy, holistic approaches to taking care of one’s physical and mental health.
That is usually what is best and most effective, for the brain, the heart, and the aging body.
Questions? Comments? Post them below!
Most informative! Thank you for good advice for healthy lifestyle living.
So glad you found it useful!
One of the best article so far I observed
May God bless you and grant you abundance of everything
Thank you, glad you found it helpful.
Thank you for making it simple for us to understand our bodies, and what we have to do to help ourselves age healthily. Please keep up the good work.
You are very welcome!
Thank you, for the detailed information including cause and remedies.
i would like to say thank you for the informed articles i have just read having just been diagnosed with small vessel ischaemic disease. I will now feel better informed when I go to see my Gp to ask the right questions i need to ask. I will be taking on board your advice on how to improve my diet and lifestyle. such a well written easy to undertand article I will come back to your website again.
I’m so glad you found the article helpful. Thank you for being part of our community!
You helped me understand the lab and radiology reports done when I suffered a left brain stroke with white matter disease. We have dementia in my family so I seem to be headed in that direction. Thanks for telling me how I can age healthily. I will take your very informative article to heart and make drastic lifestyle changes. This is a wake up call for me! Thank you for sharing!
I’m so glad you found this helpful, and even happier to find out that you are taking action to better understand and improve your own health. Good luck and take care!
You convey complex information in a way that’s clear and useful, and help us make sense of the resarch literature. Appreciated your discussion of psychosocial issues and factors such as chronic sympathetic nervous system arousal and its relation to cardiovascular disease.
By the way, is there a test for C-Reactive protein? Do you ever recommend it? I can see my PCP rolling her eyes….
Thanks!
Glad you find the article helpful and thank you for your feedback!
Yes, there is definitely a test for C-reactive protein, I have linked to the Medline page explaining the test in the article, or you can find it here.
If you decide to bring it up with your PCP, one possibility would be to explain that you are thinking of making significant lifestyle changes in an attempt to reduce cardiovascular risk, and would like to get a baseline on your inflammation levels. This way, you can check again in a few months and perhaps have a sense of whether what you are trying is worthwhile.
Here is a study on diet and CRP levels: Diet quality is associated with circulating C-reactive protein but not irisin levels in humans.
Otherwise, you probably already know this, but you can generally get more out of talking to your PCP using sensible communication strategies:
– use “I” messages and talk about what you need and why
– tell the person you’ll appreciate your help with this
– frame this as a way to work towards a goal that your PCP will have difficulty disagreeing with
– politely invite her to explain any reluctance or concern she has. The goal is for the two of you to understand each other better, so you can be better partners in maintaining your health.
– politely remind her that it’s your health and you’re concerned and eager to take good care of it
Good luck!
Leslie, I have subscribed because I appreciate and respect your perspective toward taking care of my 93 year old mother who has some dementia; and so that I can try to avoid the same consequences, if possible, through prevention. Thank you for providing such informative and unbiased, information, while being sincere. I hope you are adequately compensated for all you do!
D
Thank you, I’m so glad you find the site useful.
Since you mention it: we are not yet being adequately compensated for the time and money it takes to run the site. But I’m working to address this, as I’d like to keep the site and articles ad-free if at all possible. For now, we are starting to bring in revenue through offering paid courses, memberships, and other services that provide more information and support to those who need it.
We will soon be re-opening the doors for our Helping Older Parents Membership Community, and I would like to eventually offer some programs for older adults interested in their own aging health.
You can support us by either registering for a paid program or simply by telling others who might benefit. Even spreading the word about the free articles to others helps us. Thank you!
I’m 73 and had an MRI nine years ago due to vertigo. It found ischemic small vessel disease (not surprising as you make clear above,) My doctor then prescribed a statin drug “to knock the number way down” which I guess it is. Given that you said treatment for cholesterol is hotly debated, I’m wondering if I should consider not taking the statin. My new doctor says it’s up to me. I suspect you can’t give me a recommendation, but perhaps you could point me to some info.
Thanks for your detailed and clear discussion of this!
Statins generally reduce the risk of a major cardiovascular event by 20-30%. Your actual likelihood of benefitting really depends on how high your risk of having an event appears to be. It’s not uncommon for someone your age to have about a 25% chance of having a major event within 10 years, so if a statin reduces your risk by 25%, your risk of an event over 10 years would be reduced to about 18%, so you’d have essentially a 7 in 100 chance of avoiding an event due to taking the statin for several years.
Is this benefit worth it for you? Your doctor is probably correct to leave it up to you, assuming he’s first tried to help you understand the likely benefit and risks.
The Mayo Clinic actually offers a nice decision aid to help people with this decision:
Welcome to the Statin Choice Decision Aid
Much of the debate around statins revolves around: what level of absolute risk reduction is really meaningful? Should doctors and patients attempt to treat cholesterol down to a certain number (which was the mantra when I was in med school) or not? Do the benefits of a higher-potency statin outweigh the higher risks of side-effects? What about when people are frail and are unlikely to live another 5 years? And so forth.
For more on how to understand how likely a treatment is to help you, I recommend this NY Times article:
Can This Treatment Help Me? There’s a Statistic for That
Hope this helps, good luck!
Surely if the risk is 25% then 25 in a hundred get heart attack etc. Take a statin then 25% of the 25 brings it down to 19 will get an attack… not 7?
Yes, when the risk is reduced by ~25% then 18 of the 100 people instead of 25 will have a cardiovascular event. However, the number of people who actually avoided an event due to the statin would be 7, because some people will have an event whether or not they took the statin. Hence the likelihood of avoiding an event due to taking a statin is 7/100 = 1 in 14
This kind of calculation is called assessing the “number needed to treat” (the “NNT”). Basically, how many people have to take the treatment for someone to benefit due to taking the treatment? The NNT equals one divided by the absolute reduction in risk. (In our example above, the absolute reduction in risk was 7%, so the number needed to treat is 14.)
The NY Times offered a good explanation of the NNT a few years ago here:
Can This Treatment Help Me? There’s a Statistic for That
What advice do you have concerning hormone replacement therapy? My mother has vascular dementia, and since becoming her caregiver I have developed hypertension and am on two medications not including aspirin, although I am active. I began HRT for menopausal symptoms, and although the usual advice is to take it for the shortest possible time, if there is any protection from cerebral small vessel disease, I would want to stay on it forever; I don’t care about any additional cancer risk.
Thank you for this site; it’s very informative.
I’m not able to research hormone replacement therapy in depth. Generally, the key study of women on menopausal hormone therapy found that it increased the risk of cardiovascular events, including stroke.
I took a quick look in the medical literature, and here are two studies on hormone therapy and brain MRI findings. Looks like the women on hormone therapy fared slightly worse.
Change in brain and lesion volumes after CEE therapies: the WHIMS-MRI studies
Postmenopausal hormone therapy and regional brain volumes: the WHIMS-MRI Study
Now, the research does suggest that the timing of hormone therapy (meaning, at what age you take it) makes a difference to cognitive outcomes. This issue is discussed here:
Is Timing Everything? New Insights into Why the Effect of Estrogen Therapy on Memory Might be Age Dependent
Prescribing menopausal hormone therapy: an evidence-based approach
You may want to get an opinion from an expert in menopausal hormone therapy, as they would be best qualified to give you good information and help you with your decision.
Thank you for adding much needed clarity to this problem. I suffered a stroke , in the back of my brain 3 years ago which only gave symptoms of Vertigo and was subsequently treated as such by my doctors and it was not until 3 months later an MRI scan ( requested by a locum ) revealed that an area at the back of my brain was dead and also there were over 60 small “white areas ” showing in the MRI sections.
I am in my late 60’s and was advised by the consultant to ” go out and enjoy myself”
I have been put on statins and Asprin and also stepped up the exercise and joined a Ukuele band so am following some of your recommendations already.
I still suffer from dizziness , especially if I look up at the sky and recently walked in a semicircle when I intended to go in a straight line ( will keep my eye on that ).
I do however have a query in that I have been taking Calcium and Risedronate for many years to treat Osteoporosis and wondered if this could contribute to calcifying blood vessels leading to, or in the brain?
High levels of blood calcium have indeed been associated with calcification of blood vessels, and research suggests that calcium supplements (but not really dietary calcium) might promote spikes in blood calcium levels. A recently published study did find a correlation between high-dose calcium supplements and stroke:
Risk of Ischemic Stroke Associated With Calcium Supplements With or Without Vitamin D: A Nested Case‐Control Study
Honestly, there is debate about just what are the cardiovascular risks of calcium supplementation, but it does appear that it’s better to get calcium through dietary sources as much as possible. Outcomes may also be better when calcium is combined with vitamin D, provided one isn’t taking very large doses of vitamin D (which I would personally define as more than 2000 IU/day; for more on my take on vitamin D, see here.)
Good luck managing your cardiovascular risk factors, sounds like you are on the right track!
I have been reading alot lately
seems all nutrients work together ie need vit K2 to transport calcium to bones instead of vessels and magnesium and vit d coq10
Yes, the body needs many nutrients. This is why it’s important to eat a balanced diet with lots of different fruits, vegetables, whole grains, proteins, etc. If one eats a variety of “real food”, most people are able to get the nutrients they need. Generally, supplements have not been shown to improve outcomes, in part because extracts seem to be less effective than actual food sources.
My husband has had MRIs of the head since 2006, the most recent MRI was 2017. He is 74 yrs old and each MRI had noted Ischemic disease of the brain, small vessel disease. The most recent 2017 MRI has diagnose him having Parkinson (probably for years). He also has low beat, wants to sleep and I raised the question to his cardiologist my concern if the MRI ischemic disease (SVD) can effect the heart. The cardiologist has scheduled a chemical (nuclear) stress test. Is this the only path to take? I read up on it and our plans are to cancel this type of stress test. My reason is the risk and its too invasive considering the health of my husband now. Have I over reacted? Thank you for any direction
The cardiologist should be able to tell you more about how risky the test is for your husband.
A separate but related question is: how likely is it that doing the test will benefit your husband? Generally for a test to be beneficial, it has to give you information that you can act on, to improve a person’s health. In other words, it has to change how your husband and his health providers would manage his heart health, or some other aspect of his health care.
He certainly might have some heart disease, many men of his age do. But in many cases, the sensible way to manage this is by controlling cardiovascular risk factors.
Now, there may be other reasons that the cardiologist has recommended the test. I would recommend asking him to explain how doing this test is likely to help your husband. Also you can ask how this helps evaluate or treat any symptoms you are especially concerned about, whether that is a slow heartbeat or his sleepiness.
Ask your doctor more questions should enable you to make a better informed decision about whether to proceed. Good luck!
Thank you very much for your information on PVM.
These articles and the feedback comments have been
so helpful. Do you have any recommendations regarding
Iodine ie: Lugols supplementation…re: thyroid nodules?
No, if you are concerned about thyroid nodules or considering iodine supplementation, I would recommend discussing it with an endocrinologist as they are the specialists best suited to advise you. You can also search Pubmed for “iodine supplementation” or “iodine supplementation thyroid nodule” and see what comes up.
My husband was put on Metformin by a doctor(neurologist – for peripheral neuropathy) who seems to insist he is pre-diabetic every time he goes to see the doctor, though no diabetes has developed in years.
I was very interested in your note above:
“Research suggests that a hemoglobin A1C of 7-7.5% may be safer than using glucose-lowering medications to get the hemoglobin A1C below 7.”
But the link (https://medlineplus.gov/a1c.html) says nothing about research into using those numbers. Could you please provide the correct link if you have it – I am very interested in him not taking too many meds. Medication review with a pharmacist has only produced ‘talk to your doctor.’
Thank you for the link.
The links to the research suggesting an A1C of 7-7.5% may be safer is presented in the sentence above, where I write “That said, studies find that reducing blood sugar too much via medication is also associated with increased cardiovascular risk (see here and here).”
However this research was done in people with frank diabetes. Someone who has prediabetes by definition has an A1C less than 6.5. There is a different research base for the use of metformin in people with prediabetes. Generally it helps prevent or delay onset of diabetes, and may reduce cardiovascular risk as well.
Therapeutic Use of Metformin in Prediabetes and Diabetes Prevention
After telling my PCP that I experience vertigo and double vision, I received an MRI with and without contrast. LATER, the dr.s office called to tell me the results were all good. Then I read the report by the doctor reading the results, and learned I had small vessel ischemia. As a 64 year old female, weren’t those findings significant enough to tell me?
I can’t say what your doctors should’ve done. I will say that it seems quite common for health providers to not particularly mention this type of MRI finding to patients, I think that’s in part because it’s quite common and also because the MRI findings have unclear correspondence with symptoms.
I recently came across an article that explores this, you may or may not find it helpful:
Clinicians’ perspectives on incidentally discovered silent brain infarcts – A qualitative study
In your case, I’m not sure your MRI findings qualify as “incidental” because you did have concerning symptoms that prompted the MRI. (The answer to this question may depend on whether your findings are in a part of the brain that could relate to vertigo and double vision.) You may want to ask your doctors if they think your MRI findings might have anything to do with your symptoms. Good luck!
I have just found out that I have small vessel ischaemic disease of my brain, and at 55 years old what my neuro told me today has left me sad and very shocked. I don’t understand why now I have until having just rid my self of rectal cancer, the cancer treatments have left me with neuropathy in my legs I am in pain24 7. discs l3 l4 l5 are crumbling I have stenosis and lumbar spondylosis in my back. oh and I am dealing with epilepsy, the small vessel ischaemic disease of my brain is nothing to do with the epilepsy.
This is unreal whats going on with me, I have to just get on with it. Kevin
Sounds like this is a difficult time in which you are having to cope with lots of health problems and now this additional news regarding your brain.
You may find it helpful to look for a supportive community either online or in person, to help you process what you’re going through and to provide some encouragement. Many people find it helpful to connect with others facing similar health problems.
Regarding chronic pain, it can also be helpful to enroll in a comprehensive program to help you learn to better cope with ongoing pain, such as this one
Chronic Pain Self-Management Program.
Good luck!
Thank you Dr. Kernisan for all of your helpful info. Last fall, I was diagnosed w. severe csbvd at age 68, along w. high blood pressure and pre-diabetes. currently the new blood pressure meds have helped. Never ate much saturated fats except as a child on the farm but I do eaten a low fat diet for decades. One thing I noticed was that my memory is poor compared with having an excellent memory 3 yrs. ago, I also mentioned to the doctor that my IQ feels like it dropped 2 standard deviations and it’s been 2 yrs. since I read a book (augments headaches)) and I forgot what happened when picking up the book again. I live w. notepads and small pocket books to write down info and find it easier to use audio books downloaded from the local library’s website. As a person who has never had headaches I am finding having them daily is very hard to deal with. Tylenol 2 isn’t helping, being in a dark room and avoiding loud noises does help but that’s a confined life. How common are severe headaches w. csbvd? Thank you for all you do!
Mark
Sorry to hear of your situation. I know that research has found an association between migraines and cerebral small vessel disease, but otherwise I can’t say just how common it is.
I would recommend you consult with a headache or migraine specialist. Alternatively, you could try to find a specialist (at an academic medical center) who is studying the relationship between migraine and small vessel changes. The important questions in my mind are:
– What can be done to reduce the frequency and impact of your migraines? It sounds like they are having a significant effect on your quality of life.
– Are there any additional approaches (lifestyle changes, medications, etc) you should consider, to help stabilize your blood vessels?
Good luck!
Hello Dr.Kernisan,
Thank you for such an amazing blog!! If you don’t mind, I have a question about my father:
Background:
Father is s 81 years old, lives alone in India. He is physically (daily exercise bike and walks) and socially active. He is 5 ft 3 inches in height, 123 lbs in weight, but his waist size is 36.5 inches. My father eats a healthy vegetarian diet of brown rice, nuts, fruits, vegetables. His total daily calorie intake is 1800 – Carbs : 277 g
Protein : 50 g and Fat : 57 g
Test Results:
His PCP does routine tests every 6 months. His LDL last month was 115 (was 103 in March and always less than 100 before that). A repeat lipid profile was done last week and the LDL was 101. All other values in the lipid profile are normal. His HBA1C from last month was 5.6. He has hypertension which is well controlled with a daily 5mg of Cilnidipine.
Most Recent adverse event:
On the morning of June 27, he felt dizzy as he was brushing his teeth and had to lower himself down on the bathroom floor. He went to ER – after a CT-Scan of the brain and a cardio-evaluation (Echocardiogram, Cartoid Dopple and Holter Monitor), the Cardiologist said my father does not have any cardiac problems.
Recent new Medication:
The PCP has prescribed Atorvastatin (5 mg) for 20 days. If my father has no side-effects in the 20 days, he was asked to take Atorlip for 6 months. When I asked the PCP why is the statin medication needed, he advised that its given as a preventive measure for heart attacks/stroke as my father has hypertension. He also said since the normal dosage for Atorvastatin is 80 mg, he does not expect any side-effects with 5 mg.
Question:
Does my father really need Atorvastatin at this time? Could he have serious side-eefects?
Thank you,
Zent
Please see my comment above, in which I discuss an approach to determining whether a statin is worth taking. The comment includes a link to a statin decision aid.
You might find it helpful to review the statin decision aid with your father and/or with his health providers.
Good luck!
Generally, statins are well-tolerated, especially at lower doses. There is probably a little higher risk of side-effects with higher potency statins, such as atorvastatin and simvastatin, and some research suggests that there is less risk with a lower potency statin such as pravastatin.
Hi Dr. Kernisan,
Thank you for this gift of an article. I just found out I had …white matter T2W FLAIR hyperintensities seen in chronic microvascular ischemic changes… results also listed considering empty sella syndrome. My rehab doctor ordered the cervical spine and brain MRI for my cervical radiculopathy (>5 years). He told me to let my psychiatrist (whose treating me for mood disorder) read the brain MRI results. My psychiatrist recommended I see an endocrinologist and a neurologist. I’m only 43.
I don’t have hypertension, diabetes, nor high cholesterol. But I am a heavy smoker for years. I’m probably obese. I am a stress eater, and I don’t exercise enough.
I will follow your recommendations, but it will be difficult. I feel stressed, more than usual.
Isay
Glad you found the article helpful and thank you for sharing your story. Yes, it can be very difficult to quit smoking or change one’s eating habits, especially when one is concurrently dealing with a mood disorder. It can help to take a comprehensive approach that includes therapy and lots and lots of support. Keep at it and I am sure you will make some improvements to your health. Good luck!
I think this article is very interesting and helpful. I have seen several articles that seem to suggest that there might be a link CSVD and migraines with aura. What do you think of this possible link and are there recent/ongoing studies?
Glad you find the article helpful. Yes, migraine has been associated with small vessel disease, as reported here:
Migraine and small vessel diseases
To check for the most recent studies, you can enter this article in Google scholar and view the list of studies that have cited it.
I am not a neurologist or otherwise expert enough to have an informed opinion on the research for this topic. From a practical perspective, the issue would be is it useful to treat people with migraines in a specific way, to improve outcomes related to CSVD. As far as I know, this question has not been answered. It’s much easier to find a link than it is to identify and validate actual interventions that make a difference in people’s lives.
Very informative. I learned a. Great deal about CV disease. I’m experiencing vertigo and had both a CT and MRI of my brain. Results showed chronic micro vascular ischemic disease. Your research helped me understand the problem and assisted me in formulating specific things to do in the future (exercise, diet, etc.). Thank you so much. Gordon Cowan age 72
Wonderful, I’m so glad you found the information helpful.
My children gave me an I Watch for Christmas…has been a godsend for measuring right amt of exercise…also dowloaded a sleep website which measure amt of sleep, deep sleep etc../.found both makes me more aware of health issues at age 83…ha
Great that you are being proactive about your health in this way! Thank you for sharing.
Excellent article. Thank you, again !
Questions.
Elevated blood sugar after a meal is a risk. Why are blood tests done when fasting?
I’ve read of testing the calcium in your vessels. What test, if any, seems useful today for someone in their 70’s without symptoms. For a baseline probably.
Quest Diagnostics now has blood tests you can order (and pay for). The Inflammation Marker (C-reactive) is $59. Is there a benefit in having this test? Note, I did their test of antibodies of MMR and found peace of mind to know at age 70 I have immunity to all 3, not sure what diseases I had as a child and with the measle outbreak, am hearing on the new to get a booster as an adult, this blood test seemed more simple to decide if I needed a shot of not.
Both fasting and post-meal (technically known as “post-prandial”) blood sugar measurements are useful. I think health providers have focused on the fasting measure because it is convenient to check along with fasting cholesterol. But some people who are very serious about their glucose metabolism will check fasting and post-meal sugars, with a glucometer, even if they do not have a diabetes diagnosis. I think there is value to doing this for people who have an elevated fasting blood sugar, since the post-meal glucose check can help them understand which specific foods trigger higher glucose levels.
The US Preventive Services has studied coronary artery calcium and in 2018 declared that the evidence was insufficient to recommend for or against. See here.
The conventional risk factors used in the American College of Cardiology risk calculator are age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure lowering medication use, diabetes status, and smoking status.
As I say in the article, using the inflammatory marker C-reactive protein for cardiovascular risk screening is controversial, in part because it’s not clear that it improves outcomes compared to using just traditional factors to estimate risk. Personally, I think checking CRP can be useful when one is concerned about ongoing inflammation being related to diet or stress, as a marker that one can follow as one adjusts other lifestyle factors. But this is not an approach proven by research.
Any single target BMI you would advise? I’ll bet it is the low end of the “normal ” range.
Great work you do. Thank you !
Thank you, glad you find the work useful.
Generally, a BMI of 18-25 kg/m2 is considered normal, BMI 25-30 kg/m2 is “overweight”, and BMI ≥ 30 kg/m2 is obese.
I have not researched the details of the normal category. Even at a given BMI, some people have larger waists and/or higher levels of body fat, which generally correspond to increased risk. It’s also quite plausible that the low end of normal BMI might be associated with lower CV risk, but I haven’t researched the question.
From a practical perspective, if someone seems to be above normal weight, what’s most important is to help them improve their diet and activity levels, and to start by aiming for a 5-7% weight loss.
I take medication to control my blood pressure and cholesterol, and in both cases the medication works well. Are these therefore no longer risk factors, or does the fact that I have them under control medically not matter, and they are still considered risk factors?
The best known risk calculator (AHA/ACC) does take into account current BP and cholesterol, and also whether a person is taking medication for these conditions. Hence, even if one is being “well treated”, there is still risk associated. But it’s less than if those conditions aren’t well treated.
This and the article on small vessel disease are helpful. I had an MRI after some vertigo and no link to that found, but the report noted mild chronic microangeopathic changes. I’m 70 and got worried, so glad to learn that this is really not so uncommon even in a healthy, active, fit (mentally and physically) older adult. Thanks!
Yes, mild chronic changes to the brain’s small blood vessels is very common in people age 70. Glad you found the articles helpful!
The article was an excellent explanation about cardiovascular risks and the ways that we can do to prevent the risks .I agree that sometimes we know how to do something but we don’t really make an effort to help ourselves. Thanks for enlightening information in this article.
Thank you for the feedback!
I think this site is fantastic and would like to help you if you go on patreon for example.
I have a question though. You say high LDL is a risk factor. Surely it is the particles – volume – not LDL itself? Also if so, then surely extra tests such as VAP/NMR are necessary – and a PLAC test?
Thank you
So glad you find the site useful. Nice to know you would support on Patreon if we ever go that route!
So, I generally convey “mainstream” geriatrics and internal medicine information, and almost everything I share is in line with what is recommended in Uptodate.com. (Among other things, I simply don’t have the bandwidth to assess the bleeding edge of research and medicine myself.)
As far as I know, in most cases it’s appropriate to just consider LDL itself and additional tests related to particle size should only be considered for certain particular cases. In the UptoDate.com chapter Measurement of blood lipids and lipoproteins, the summary includes this statement “We do not advise the routine measurement of LDL particle size or concentration (number), lipoprotein levels, or the use of “ratios.”
They also say “In high cardiometabolic risk patients, such as those with diabetes, where the disconnect between LDL cholesterol and LDL particle size is greatest, the measurement of LDL particle size may be of benefit for improving risk stratification and as a guide to titration/adjustment of lipoprotein modifying therapy”.
Hope this helps answer your question. I’m not a cardiovascular risk specialist so can’t speak to the additional tests you are referring to.
Also… you gave a link to a ‘statin decision tool’. This is only applicable for primary prevention: https://statindecisionaid.mayoclinic.org/
What about for secondary prevention i.e. if you have had a stroke, recovered and now wish to assess risk?
Also you are excluded if you have had a stroke. What if the ‘stroke’ was a TIA. That’s a stroke…and yet it’s transient so has gone so….you’ve not had a stroke?
People who’ve had TIAs are supposed to be treated for secondary stroke prevention, same as people who’ve had an overt stroke. Statins are recommended for secondary stroke prevention for everyone who’s had a previous stroke or TIA, independent of LDL level.
For help assessing secondary stroke risk for yourself or someone else, I would recommend consulting with a neurologist experienced in stroke. I don’t myself know of a general calculator for evaluating secondary stroke risk.
I am 49 and I suffer from tia’s 3-15 a day longest ones last 7-8 min. mostly 1-5 min. I have been having these for about 2 yrs. last November I had 3 strokes one took vision in right eye and the other 2 took speech and coordination. Is there anything I can do other than blood thinner and eleviate stress to get these to stop?
This sounds worrisome. I would recommend working closely with a neurologist and getting help with what is called “secondary stroke prevention.” The specific things to do often depend on what they think is the underlying cause of your strokes or TIAs, and may also be related to other aspects of your health and medical history.
You can also look on Pubmed for free articles on stroke prevention, such as this one: Secondary stroke prevention: challenges and solutions. Good luck!