Assessing and treating cognitive dysfunction is a challenge. The problems can show up in myriad ways, with multiple potential causes. Cognitive impairment is often connected with, and reflective of, disease and dysfunction in other organ systems. Though surveys consistently show that many people worry about developing dementia, individual patients may not always be forthright about their concerns.

It may be tempting to refer patients to a neurologist at the first indication of significant cognitive problems. But this is not always the best course of action. There’s much that primary care practitioners can do to mitigate cognitive dysfunction—especially in the early stages. In fact, neurology consultations may not even be practical in many cases. In some regions, neurologists are few and far between. Wait times can be months-long.

So, how to find the beacons in the fog that will help you and your patients deal effectively with cognitive problems? How to discern when a case truly requires specialist expertise? What are the most effective nutrition and lifestyle-based approaches for early or mild cognitive impairment?

To explore these, and other issues, Holistic Primary Care spoke with Corey Schuler, PhD, FNP, CNS, one of the nation’s top holistic practitioners. Schuler is a family nurse practitioner at Synergy Family Physicians in White Bear Lake, MN, and has extensive experience using non-pharma approaches to cognitive problems. In addition to his clinical work, he also serves as medical affairs director for Allergy Research Group.

Erik Goldman: First off, tell us how do cognitive problems show up in your clinic? Do people come in saying, “Hey, I’m really concerned about my cognitive health?” Do they describe specific symptoms they’re having? Or is it something you have to draw out of them?”

Corey Schuler: It’s a good question. My patients tend to divide really distinctly. Typically, the people suffering from longer term memory loss that fit more into the dementia-neurodegenerative category, usually aren’t the ones complaining about it. More likely, it’s the partners, the spouses, who come in with them and say, “Things aren’t the way they should be.”

At the opposite end are young executives, the high performers. They tell me right away, “Something’s not right. I’m feeling older than I should be. My mental clarity is not where I want it to be. Help me help me.” So, it’s a significant divide.

EG: Holistic, functional, and naturopathic medicine all posit that cognitive problems reflect other systemic imbalances. They don’t necessarily start in the brain. There’s a lot under the tip of the “cognitive impairment” iceberg. How do you unpack that clinically?

CS: This is a “peeling of the onion” situation if there ever was one. Alzheimer’s and blood sugar dysregulation go hand in hand. We know that now. So that’s the first thing we try to rule out. I’ll go as far as doing CGMs (continuous glucose monitors) on these individuals.  If I can rule out dysregulated glucose metabolism, then I proceed to other questions like, Is this a neuro-inflammation thing? Is it more of a long-term thyroid issue? An autoimmune problem? Is it related to gut problems?

But first we have to determine if it is actually cognitive decline, or if it is more on the occasional working memory side of things.

We sometimes send patients out for the Montreal Cognitive Assessment (MoCA), even though they get really irritated with me, and the wait for a neurologist is longer than it should be. I’m not trained to do the 30-question MoCA, so I send that out. And we screen for depression and anxiety, and do our best to screen for ADHD, which all show up in similar ways.

EG: Once you’ve ruled out glucose dysregulation and serious neurodegeneration, how do you make sense of all the other potential variables?

CS: I try to get an understanding of what the core symptoms are: Is it actually memory loss? Is it face-name allocation? Is it focus and attention? Word-finding? Mental fatigue? Is this a dopamine issue? That’s an important one, because a lot of common medications like Ritalin, Adderall, those sorts of things–they stimulate big dopamine surge, and then a big crash down. It’s an important thing to assess.

Alcohol also boosts dopamine, which makes that poison so pleasurable. But the day after, it can cause a big dopamine crash. So, when I look at mental fatigue and focus problems, I wonder if it’s a dopamine issue. It becomes top of mind because of the wide use of those drugs, including alcohol. It becomes complicated when somebody has ADHD, and on ADHD meds, and then they have an additional layer of brain fog. That can be very confusing to sort out. Often, we do a drug holiday to identify if it’s still present without the meds.

“Alzheimer’s and blood sugar dysregulation go hand in hand. So that’s the first thing we try to rule out. I’ll go as far as doing CGMs (continuous glucose monitors) on these individuals.”

Sleep apnea and hearing loss are also important to consider. They’re sort of boring, but very, very real. There’s a nice body evidence that shows hearing deficits and cognitive function are intimately related. Those cases are usually refer-outs, maybe a sleep study, if they’re having trouble sleeping. If there’s any hearing deficit, I want to get to that as early as possible. A hearing aid is better than neurodegeneration.

Occasionally, we have to do a deep dive, to assess if there’s inflammation related to a latent infection. I do screen for inflammatory markers, as well as Epstein-Barr virus, Lyme disease, and mold mycotoxins, if there’s any suspicion for any of those. These can be expensive panels to run, but anything I can find that I can work with, I will do.

EG: Once you have a sense of the main drivers, how do you go about treating them?

CS: First, we do the foundational stuff that everybody should be doing. Good, healthy living. Right away, I tell patients, I want them to do 20 minutes of regular walking a day. There was a study that showed like 15 minutes of fast walking—and this was in a lower income group–improved overall health and reduced morbidity and mortality. Just getting outside, especially before 10 AM, a few times a week is so beneficial.

Being outside and taking time to wonder about the world is so beneficial. It is a form of meditation that’s easier, I think, for some people to grasp, than formal techniques like transcendental meditation or other versions.

Sleep hygiene and sleep consistency are super important. I pay close attention to that. And I do encourage patients to meditate, and to exercise if they haven’t been exercising. It can take a while to implement if they’re not already doing it.

I drop right into supplementation very quickly. The process takes a while, and it takes time for the interventions to make any real difference. I say to patients that our trials of therapy are going to be about 90 days, and I’m going to stack the supplements as best I can. But it will take time, and it’s a lot of supplements.

“I am cavalier with L-theanine. My starting dose is 400 mg, which I know is on the high side. Sometimes that’s 200 mg twice a day, and sometimes 400 all at once.”

I base that 90-day projection on one of my favorite nootropic supplements, which is spearmint. The Neumentix ingredient, from Kemin Labs. In a clinical study it showed no real effect after 60 days. But after 90 days, it was very impactful.

I think it’s an unsung hero. Five clinical studies have been done on it. There’s also a version of spearmint and EGCG together, for sleep.  Dr. Andrew Tubbs, a neuroscientist at the University of Arizona, did a study of that and saw results in next-day mental clarity within 30 days.

So, I have a strong opinion about that one. I’ve tried a lot of nootropics and most are overly stimulating. Neumentix is not. So that, and L-theanine are at the of top of my list. Citicoline and omega-3 fatty acids are also on the list, but most people have already tried them when they come into our clinic.

Typically, the people suffering from longer term memory loss… usually aren’t the ones complaining about it. More likely, it’s the partners, the spouses, who come in with them and say, “Things aren’t the way they should be.” At the opposite end are young executives, the high performers. They tell me right away, “Something’s not right…. Help me help me.”

For a very few supplements—Bacopa maybe one of them, and perhaps Lion’s Mane– sometimes you get an early response. But most other supplements will need a long time to have an effect.  

Two things that people often overlook are DHEA and pregnenolone. I’m relatively cavalier with these two. I dose DHEA based on the patient’s IGF-1 status. If IGF-1 is too high, there’s cancer risk. If it’s too low, frailty risk. I usually find that people that have cognitive dysfunction are on the lower side of IGF-1, and low DHEA. I can get a big benefit on sleep and brain function with DHEA.

Some people respond well to pregnenolone, but it is a goofy one. There’s a study that looked at 30 mg of pregnenolone versus 100 mg, and some people did better on the lower dose. So, I have to be a bit careful with that. I start at 100 mg. And if they feel more depressed, or they have mood lability, I will back down to 30 mg or even lower.

EG: You mentioned Spearmint, and Bacopa. What are some of your other go-to brain and cognitive supplements?

CS: I am cavalier with L-theanine. My starting dose is 400 mg, which I know is on the high side. It goes as low as 50 mg. I just scoot right past that and go right to the 400 mg. Sometimes that’s 200 mg twice a day, and sometimes 400 all at once.

Acetyl L Carnitine was popular years back. Robert Crayhon (the influential nutritionist/educator who co-founded Designs for Health) introduced me to the power of this ingredient. And he taught me a trick, which is not really a trick. He explained that when you see triglyceride elevated, remember that carnitine shuttles triglycerides into mitochondria. So, if you see high triglycerides and especially if they’re not eating an ugly high-sugar diet, think “mitochondria,” and give them L-carnitine. That has stuck with me for over 20 years.

EG: Is that something someone would stay on indefinitely?

CS: I think it can be. We top out at about 1,500 mg, because there is some risk of thyroid function suppression with very high-dose acetyl L-carnitine. But I’ll go as high as that 1,500 mg, if that’s what it takes to give them the benefit. And then I try to cycle them down to lower doses, and support them in other ways. But, if they’ve been on acetyl L- carnitine, high dose, for a year or so, and that’s all that seems to be helping them, then I think I’ve missed something. And I need to go back to the drawing board.

Spearmint is one of my favorite nootropic supplements, particularly the Neumentix ingredient, from Kemin Labs. Five clinical studies have been done on it. I’ve tried a lot of nootropics and most are overly stimulating. Neumentix is not. I think it’s an unsung hero.

EG: Say more about sleep. Roughly, what percentage of the cognitive health game is won simply by normalizing and re-regulating people sleep cycles?

CS: In my practice, it’s probably 60 to 75%, in that range. Even those who say “I’m sleeping fine,” usually are not. Once we start using wearables, and figuring out what someone’s duration of sleep actually needs to be– like, how much do they need to sleep without an alarm before they can wake up, and after an hour of being awake, feel well rested—we start getting at the truth. I’ve rarely found people needing less than eight and a half hours, every single night. And very regularly, like regular bedtime, regular wake time.

I know we hear that a lot. And we brush it off like, “Oh, yeah, yeah, but I have a life and I can’t really do that.” But it’s so important. It’s actually the biggest lift I can find. As soon as somebody figures that out and they dial that in for a while, when they go off of it for whatever reason, they absolutely know it. It’s sort of like the people that find out that they’re sensitive to gluten, so they stay away from it, and then when they’re reintroduced to it, they’re like, “Oh, that was terrible.” It’s the same with sleep.

“Sleep hygiene and sleep consistency are super important. I pay close attention to that. I’ve rarely found people needing less than eight and a half hours, every single night.”

EG: What are your thoughts on coffee and cognitive function? You said before that alcohol is problematic for people with cognitive issues, and there seems to be consensus on that. But there’s a lot of controversy about coffee. What’s your what’s your take?

CS: Well, I’ve a biased opinion, because I like coffee! We do know that there’s some metabolic benefit to it, whether it’s from the chlorogenic acids or some other phytochemical complex in the coffee. It seems to benefit both blood sugar metabolism and probably cognitive function. But when you get into the atrial fibrillation range of like four or five cups of coffee, that’s probably too much.

One big problem is that people don’t know how to portion their coffee anymore, thanks to commercial entities, saying, “This is a cup of coffee,” and it’s 32 ounces! So, we need mediate based on caffeine intake.

For some people, coffee is a huge uh no-no. This is just purely my own speculative clinical thought, but it seems that women in perimenopause tend to do really great when they cut out coffee, even if they’ve been coffee drinkers their whole lives. Hot flashes, night sweats, vasomotor symptoms seem to improve rapidly. So, I’ve learned to be okay with saying that coffee is not okay for some people.

And there are nice coffee alternatives now. Dandelion root tea is awesome because it has a dark roasted flavor, and some other aspects of coffee. And now there’s all these mushroom teas and coffees, and things like that. Finding a palatable replacement is just a lot easier now.

“If there’s any hearing deficit, I want to get to that as early as possible. A hearing aid is better than neurodegeneration.”

EG: You’ve said that your treatment protocols are 90 days, minimum, and that it often takes even longer to optimize cognitive function. How often do you see the patients during the course of treatment? How do you guide patients through the process?

CS: I’m really clear with them. I let them know, we’re going to see each other every four to six weeks, and we’re going to keep each other on track. We’re going to do labs every 12 weeks. And you’re going to monitor the heck out of yourself. I tell them not to go nuts, because we don’t want to increase anxiety. But I suggest they get an old-fashioned notebook and pen, and write down all of their stuff. The point is to stay off the phones!

I try to create systems that work for each patient. I’ve had people do calendars with smiley faces. Other people like numbers, so we decide these are the five symptoms we’re going to track on a 1-5 scale, on either a daily basis or even multiple times a day basis. I want to know the mid-morning, mid-afternoon, and early evening mood and energy profiles. So, they end up filling their notebook full of stuff. And when we get together in six weeks, we squint and see if we can detect some patterns.

EG: Do patients stay on your supplement protocols indefinitely? Or is there a point at which they can discontinue without any negative consequences?

CS: Well, we are evaluating and adjusting all along the way. Often, there comes a point where it’s like, I can keep pushing and trying to optimize, optimize, optimize. But it may not be worth the time, the energy, and the cost. I always tell patients that I’m like a dog with a bone with this sort of stuff, so they’re gonna have to call me off! Periodically, we need to evaluate and assess what’s worth continuing.

Sometimes, a patient is not really experiencing improvement despite our best efforts. There may be something going on that’s out of my league. Luckily, I have some trusted functional neurologists that can take the next steps with them. Oftentimes these functional neurology people see things that I just wouldn’t have ever thought about.

EG: Are there any emerging cognitive health herbs or nootropic ingredients that you think will be impactful in the next few years?

CS: Well, there’s a renewed interest in polyphenols. A lot of cognitive dysfunction is ultimately due to oxidative stress. Vitamin C and other vitamins, and even CoQ10 fall short. So, I think from an innovation standpoint, we’re going to see the next generation of cognitive tools be polyphenol- or flavonoid-based. Berries are going to be our best options. There are the exotic “superfood” berries—Maqui and Wolfberry (aka Goji), and so on. But it might not need to be that. It might be just good ol’ blueberries. Can’t say enough good about blueberries!

EG: Okay, last question: What does Allergy Research Group offer in the cognitive health space?

CS: Our Advanced NeuroPlus is one that is of interest. It contains that Neumentix spearmint I mentioned, as well as citicoline, and lion’s mane…it’s the whole ball of wax. It’s pretty broad. It also has a coffee fruit extract, but it’s really minimal caffeine. So that one is a really good, useful product.

And because of the recent introduction of the Metabolic Maintenance product line into our portfolio, we now have one called MetaCalm, for the people that lean towards anxiety. And then MetaMIND …that one has Nutricog (a fixed combination of Boswellia and a south Asian herb called Haritaki). So that’s likely working on the neuro- inflammatory aspect. And it also has lutein and zeaxanthin in it, which I really like because of the blue light blocking effect. We’re developing our own body of evidence on these two carotenoids, looking beyond blue-blocking, an actually looking at cognitive function. So, MetaMind is a really nice addition to the portfolio.

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