A neurologist’s warning about Alzheimer’s often arrives too late. The disease typically emerges in the 60s or 70s, but the biological changes that precede it can begin much earlier—sometimes in the 30s or 40s. This early period is the focus of Kellyann Niotis, M.D., a preventive neurologist who insists Alzheimer’s is not an inevitable outcome, even for those with genetic risk factors.
“That was the take-home message from the recent conversation I had with preventive neurologist Kellyann Niotis, M.D., on the mindbodygreen podcast,” she said. “What we know for sure is that Alzheimer’s is a preventable disease. It’s not destiny. Your genes don’t dictate whether or not you will get this disease.”
While general advice about diet, exercise, and sleep is widely known, Niotis rejects broad recommendations. Instead, she identifies seven targeted strategies—some clinical, others behavioral—that can reduce risk before symptoms develop. The first step, often overlooked, involves a thorough cholesterol assessment.
Cholesterol’s Role Beyond Heart Health
Patients in their 30s and 40s frequently receive reassurance when their cholesterol levels fall within acceptable ranges, even if they are only slightly raised. Yet these same numbers correlate with increased risks of both cardiovascular disease and cognitive decline. A single test measuring ApoB, a protein that transports harmful cholesterol, can identify vulnerabilities years before they become critical.
One individual who monitors cholesterol closely described the difficulty of lowering ApoB through diet alone. Despite strict limits on saturated fats, their levels remained at 71. A physician later prescribed ezetimibe, a medication with minimal side effects, which reduced the number to 51 within months. This experience highlights that when lifestyle changes prove insufficient, medication can fill the gap.
“If you need a medication, great,” Niotis says. “We’re equal opportunists when it comes to the brain. We’ll do lifestyle, medication, supplements, whatever works.”
Movement as an Early Indicator of Brain Health
Niotis’s expertise in movement disorders provides a distinct perspective: how people move in their 30s and 40s can reveal early signs of brain changes. She works with trainers to evaluate “motor reserve”, the brain’s efficiency in coordinating movement without relying on visual cues. A simple at-home test demonstrates this: with eyes closed, extending the arms to touch the nose assesses spatial awareness. The closer the touch, the stronger the brain’s coordination.
Cardiovascular exercise receives less attention than strength training but plays a vital role in protecting cognitive function, particularly for those with the APOE4 gene, which raises Alzheimer’s risk. “If I can say the one thing that my patients notably benefit from in terms of cognitive function, it’s when they get on a strict cardio programming,” she told me. “Don’t sacrifice your cardio to put on muscle mass.”
A balanced approach combining both types of exercise is ideal. The goal extends beyond physical fitness to challenging the brain with varied demands. Someone who only runs might add rowing, while those who prefer low-impact workouts like yoga could incorporate high-intensity interval training to push cognitive boundaries further.
By the time biomarkers such as amyloid or raised p-tau 217 appear, the opportunity for intervention shrinks. However, even these markers do not guarantee disease progression. Biomarkers should be treated as data, not a diagnosis. Niotis emphasizes that if a person is cognitively normal, they do not have Alzheimer’s disease.
Niotis’s collaboration with trainers like Beth Lewis goes beyond basic fitness evaluations. Their assessments include subtle indicators such as gait symmetry, reaction time to balance disruptions, and the smoothness of transitions between movements. Someone who hesitates before stepping onto a curb or struggles to recover from a minor stumble may show early signs of reduced motor reserve. These patterns, often dismissed as clumsiness, can signal underlying neural inefficiencies that precede cognitive decline by years. Lewis and Niotis have observed that even highly active individuals, athletes, dancers, or those with rigorous fitness routines, can display these warning signs if their training lacks variety or fails to challenge the brain’s adaptive capacity.
The connection between movement and brain health also involves recovery. Niotis notes that how quickly someone rebounds from physical exertion reveals more than endurance alone. A 45-year-old who recovers swiftly from sprint intervals but fatigues quickly during steady-state jogging may have a cardiovascular system optimized for short bursts rather than sustained aerobic demand, a mismatch that could stress the brain over time. She advises patients to track not only workout intensity but also how long it takes to return to a normal heart rate and mental clarity afterward. This self-monitoring can uncover hidden issues, such as poor mitochondrial function or autonomic dysfunction, both linked to higher Alzheimer’s risk.
Hormonal Shifts and Perimenopause
Niotis emphasizes hormonal balance due to decades of research showing that estrogen’s decline during perimenopause accelerates amyloid plaque formation in women. Hormones aren’t the whole story, but getting them right can improve sleep, mood, cholesterol, and blood pressure. Niotis does not endorse universal hormone replacement but advocates for personalized testing, including saliva or blood panels to evaluate free testosterone, progesterone, thyroid function, and estrogen levels.
Mental Health and Cognitive Protection
Niotis’s clinical work shows that untreated anxiety and depression in midlife are associated with a higher dementia risk later in life. She distinguishes between normal stress, common during career and parenting years, and clinical conditions like major depressive disorder, emphasizing that the latter requires professional treatment. For everyday anxiety, she suggests accessible interventions: a 10-minute daily mindfulness practice or a weekly “worry hour” to document racing thoughts.
One patient, a 38-year-old software engineer, reduced cortisol levels by 30% after combining structured journaling with three 20-minute walks per week. Niotis attributes the improvement to the combination of physical activity and emotional processing, which breaks the cycle of overthinking.
The takeaway Niotis is happy to share information like this with her patients and the public, but she can’t pull the levers for you. “I wish there was the one magic thing that we did, but it’s impossible to isolate one thing,” she says. Her best advice is to pick one bucket to focus on at a time. Pick one move to make this month: ask your doctor about ApoB, add a cardio session, or block yourself off an hour to decompress. If you can make these into habits, you will be preparing your brain as best you can to fight off Alzheimer’s.