Brain Health

In this episode I talk with Dr James Beauregard, a neuropsychologist, about brain health. We talk about normal brain development and the components of developing and maintaining a healthy brain.

Those components are:

• Social interaction
• Exercise
• Diet
• Sleep
• Avoiding head trauma

We also talked about normal brain aging, and that as people get older, they may lose the speed and accuracy of recalling specific names or words. However, losing the ability to perform activities of daily living like managing our finances is not part of normal aging.

When we see concerning signs in our loved ones, we should not ignore them or write them off as things that happen when people get older. Dr Beauregard described a stepwise approach to getting to the bottom of things which begins with an appointment with the primary care doctor to look for treatable causes like urinary tract infection, dehydration or vitamin deficiency. 

Once these causes are ruled out, there are other steps such as MRI or neuropsychological testing that may better explain what is happening. According to Dr Beauregard, there are now some medications which may slow down the cognitive manifestations of Alzheimer’s dementia. 

If you are interested, please discuss with your or your loved one’s physician.

Transcript

SPEAKER_00 0:00

Live food how to live.

SPEAKER_02 0:02

Do you sometimes feel like life is passing you by? How would you like to get more out of life? We explore all things life on this podcast. Welcome to Life and How to Live It podcast with Dr. Rocco. Welcome to the Life and How to Live It podcast with me, Dr. Rocco. I am joined today by a very special guest, a good friend of mine, James Beauregard, PhD. Now we are talking today about brain health, uh, and I think that uh Jim is an excellent uh person to discuss this topic with us today. Jim and I met each other in 1998 when I was the medical director of a rehab unit in Manchester, New Hampshire. He came to the unit one day uh to do a cognitive assessment for one of the patients there, and we struck up a conversation and have been talking ever since. Now, Jim is a uh PhD in psychology with a specialty in neuropsychology. Uh he is a clinician who focuses on the geriatric population. In addition to his clinical work, Jim is a teacher and an author. He teaches psychology doctoral students and has written two books as well as journal articles on the fascinating subject of neuroethics. He has lectured both within the United States and internationally, uh, including a lecture at the Vatican on the social and ethical implications of neurotechnology. Jim, welcome to the program. Thanks for being here. Hey Rocco, thanks for having me. Great to have you here. I look forward to this conversation. So we will be talking about uh brain health. And I think that brain health is a topic that is of great importance and interest to uh so many of our listeners. We are all concerned about uh the health of our brains, the quality of our thinking and cognition. And unfortunately, uh some of us have experienced uh seeing loved ones have issues with cognitive decline. Uh so I think it's going to be a topic of interest to many people, and I think a great place to start would be to talk about brain development. Jim, can you say a few words about that?

SPEAKER_01 2:38

Sure. So the first thing I want to say about it is we really kind of begin with the understanding of the brain as it is in neuroscience today, and that understanding is captured in the word connectome. So the word connect is in there, and the way the brain is understood in neuroscience now is that it is a vast interconnected network that serves all of our cognitive processes, things like reasoning, language, memory. Our brain starts developing in utero fairly early on. But when we're born, brain development is not done. Brain development actually continues on for another three decades until we're about 30 years old. That development is about the brain making connections. So an infant is born with all the neurons it's going to need for its full life, but it will actually lose some along the way. The ones that don't get connected kind of fade away. But there's a 30-year process of connectivity, and that's that's a lot of what accounts for the brain's increase in size. You know, you compare the size of a grown-up's head with an infant, and infant's head is much smaller, but our brain does get bigger as we age. But most of that increase in size is due to the development of connections in the brain. Some of that is genetically driven, and some of it is also influenced by experience. So it's a combination of those two things. So brain development is an almost 31-year process, and we top out around the age of 30. And to those of you who are over 30, I apologize in advance, but that's when normal aging starts. It doesn't, it doesn't affect us much in any noticeable way for a couple decades after that. But then some small things will happen on the way. And one thing I want to say, given the context of what we're talking about today, is that it's important to remember as we get older that normal aging does not interfere with our ability to live our lives, to manage our own affairs, to make decisions and things like that. So, you know, a hundred-year-old, eighty-year-old, a 60-year-old, they have the cognitive capacity to manage their own affairs. And if someone doesn't, that's a big red flag that something may be going wrong.

SPEAKER_02 4:42

Yeah, I think that there may be a misconception out there in the general public that, you know, it's a normal part of aging to not be able to do things. And you're saying that's not the case.

SPEAKER_01 4:55

That's right. So given normal aging, I mean, the only real big normal aging change that happens is you know what what us neuropsychophosts call retrieval deficits. And we all experience that starting in our 50s. And it's an instance where you know, if you and I are having a conversation and I'm trying to recall a fact or a name or something like that, it might not come to me right there on the spot. But then a half hour later or a few hours later, when I'm doing something else, out it pops.

SPEAKER_02 5:20

Yeah. Well, I've experienced that, that's for sure. Yes. Usually when that happens to me, I say, okay, as soon as I stop wanting to find this memory, it'll come. Exactly. Yeah, it's very it's an interesting phenomenon.

SPEAKER_01 5:33

Yeah. And it's really what marks normal aging. So if someone is having more difficulty than that with their memory or other aspects of the thinking, that's a red flag that something's up that needs to get looked into. Okay.

SPEAKER_02 5:44

So so you were saying something I think is really interesting about connections. It's not really the actual um neurons or what's called the gray matter, but it's the connections between them that make all the difference in our thinking, our cognition, correct?

SPEAKER_01 6:03

Yes, it is. Yes, it is. And one of the things that happens during normal aging is that we lose a little bit of that connectivity. And that's what causes the retrieval deficits. Because when I want to remember something, what's happening in my brain is that I just I'm looking for a fact, and along those white matter pathways, I'm going to get it and bring it back up to consciousness. If there's a little less connectivity, then that may take me a little longer or not be as efficient.

SPEAKER_02 6:28

Okay. So so you're saying that there are these connections, and that's the key. What can people do, you know, to improve those connections? Now, I I understand that this is a development thing. So, you know, when we're thinking about kids, our own children, how can we optimize this uh brain uh development for them?

SPEAKER_01 6:51

So stimulation essentially is what's important for kids, having lots of experience. I mean, one of the cutting-edge kinds of research that's happening in neuroscience is called epigenetics. And what that looks at is the way that our brain changes its structure as a result of experience. And that does make a difference. So having our kids have lots of experiences, being able to learn in school, do different kinds of activities, those are all things that help develop that connectivity. More generally, though, there are a number of things, and I talk with this all the time about my patients who have Alzheimer's or other kinds of cognitive difficulties. There are a number of things that help keep our brain healthy and active across our lifespan. I'm just going to mention a few of those now. The first one, as simple as it sounds, is talking to people, socializing. That's the best brain exercise that we have because when we're having a conversation with somebody, all the neurons in our brain are active and working. So socializing is really the most important thing we can do to maximize brain health. The second thing is physical exercise, 20 or 30 minutes a day of moderate activity, things like going for a walk, doing yard work, just doing kind of workouts, exercise. That has long been known to be heart healthy, but more recently it's also been found to be brain healthy as well. Someone who's exercising regularly tends to have more energy, they sleep better, and they maintain better cognitive tone. So think about you know, we want to have good muscle tone and things like that from exercising. We also want to have good brain tone so that all of our thinking works well.

SPEAKER_02 8:24

Let me let me stop you there for a second. Um very interesting, this idea about physical exercise being really key to cognitive function. And uh, you know, I I it's it's something that I've discovered over the years, you know, in my uh practice as a physician, etc., is so much of of our health depends on flow, on blood flow, right? So so is is that what's happening with the you know, with the cognition? Is uh if you exercise, you're just getting better blood flow to the brain?

SPEAKER_01 9:02

That's part of it. Yes, you're getting better blood flow to the brain. So the brain is better perfused generally. And what that means is we're getting more oxygen, we're getting more glucose, you know, the fuels that our brain uses to work well. When we exercise, we're maximizing that. Also, exercise promotes good overall health and helps us with things like cholesterol, blood pressure, those types of things, because when stuff like that starts becoming a problem, that increases risk of small strokes or even big ones in the brain. So there are several things going on in terms of positive stuff that's making us healthier, but also the reduction in risks of things that can happen to us as we get older.

SPEAKER_02 9:40

All right. And then also going back to the other, the first thing you said about interacting with people, you know, having having connections with other people and how vital that is for um brain connections and connectivity. Um yeah, so so are are we saying then that you know that is uh affecting that wiring, you know, that uh connections between all the different uh axons in the brain? Yes, it is.

SPEAKER_01 10:12

And you know, one way that that is important is in memory functioning. In the research that's done on memory, say, a lot of this has been contributed to by a uh psychiatrist, neuroscientist named Eric Handel. What's known about how memory works is that our memories are actually stored in our neurons, oftentimes at the synapse where two neurons connect with each other. So that social activity, that experience is building those kinds of connections right down to the neuronal level. And that's the case of all our experience. It changes the structure of the brain. So you can say quite accurately that two identical twins, twins who have the exact same genome, do not have the same brain because they've had different experiences in life. So there's going to be subtle differences based on the experiences they have right from the get-go.

SPEAKER_02 11:01

So if two identical twins don't have the same brain, then none of us have the same exact brain. Exactly. Exactly. Interesting. You know, Jim, you said you said uh we've said a couple of words here, you know, like axons and synapses and stuff like that. Let's take a second to explain that a little bit. Could could you do that um for the folks who who who are not PhDs in uh neuropsychology?

SPEAKER_01 11:31

Sure. So neurons are a very specialized kind of cell in in the brain. And there's well over a hundred types of them that have been discovered, and maybe more that we don't know about yet. But a neuron has a similar basic structure, whatever its details may look like. So, like every other cell in the body, a neuron has a cell body where the nucleus is or a DNA is kept. Neurons have a couple of special features, though. On one end of a neuron, there are branches called dendrites, and it looks like a tree. It sort of branches out, and the dendrites' job is to receive information from other neurons. Neurons then also have one long process going out from it called an axon. That's the structure that we use to send information from one neuron to another. So that signaling is electrochemical. When a neuron decides to fire, it sends an electrical signal down the axon until it gets to the synapse. At that point, the synapse is going to release small molecules called neurotransmitters, and they diffuse across the space between neurons and then reactivate that chemical process, an electrical process in the neuron that's receiving the information. So there's a process of receiving information, a neuron firing, and then making its chemical connections with other neurons. One neuron can have as many as a thousand connections, and that goes back around to that notion of the brain as a connectome. So one neuron can have many connections, be parts of different networks in the brain in a highly active and interconnected process.

SPEAKER_02 13:00

Yeah, I mean, that's just incredible. If you say that one neuron can have up to a thousand connections, and we know that there is something like 80 billion neurons in the human brain, that is a completely staggering concept to think that 80 billion neurons may have, each one may have a thousand connections. So now we're really getting a sense of how intricate and and really uh somewhat, you know, not understandable our brains are. It's it's incre it's really fascinating. It's really fascinating.

SPEAKER_01 13:37

And you know, that there's there's additional information. There's those 80 billion neurons, but there are also support cells in the brain that help the neurons stay alive and function. They're generally called support cells, but they uh they outnumber the neurons by about five to one. So add to that 80 billion, billions and billions more, whose jobs are to make sure that neurons function properly.

SPEAKER_02 13:59

Unbelievable. It truly is is uh you know, it's humbling to think about you know each person's brain and how how intricate it is. So you were saying so you know, the things that are necessary for uh optimal development uh and maintenance of cognitive function are socialization, exercise. Okay, what what did you have next there?

SPEAKER_01 14:26

Several more things. So the next thing I would talk about is eating a healthy diet. And yeah, that across the world, that boils down to fruits, vegetables, and healthy proteins. You know, here in the U.S., where we're having this conversation, that's often referred to as a Mediterranean diet. So think about the Mediterranean Sea and all the cultures around it the seafood, chicken, lots of fruits, lots of vegetables, they do they do well health-wise. So eating that healthy diet keeps us healthy, gives our body all the nutrients it needs, and also helps keep down things like cholesterol, blood pressure, things that can cause us problems later on in life in the aging process. So keeping a healthy diet is an important thing. And one thing I always say to my patients about this is while that may sound really complicated, it's a simple thing to do. When you walk into a grocery store, all the healthy diet stuff is along the outside walls of the store. So you think about four walls of a grocery store, that's where the healthy stuff is. To the extent that we shop the walls instead of the aisles, we're eating a healthy diet.

SPEAKER_02 15:24

Yeah, I've heard the same thing. They eat uh shop in the periphery, you know, and and so that's and you'll be better off. You'll get more of the produce and the actual meats, etc. Um, what you didn't you mentioned some things that are in the Mediterranean diet, but you didn't mention olive oil. Um olive oil, you know, I think that there's something about healthy fats as being uh help help helpful for your health as well as your brain health.

SPEAKER_01 15:54

Yes, and getting healthy fats into our system are necessary. You know, one thing that I just I point to with that is that every neuron in our brain, the axons, those processes that come out and send signals, is covered by a layer of fat. And the job of that is to help speed neural transmission. So kids need healthy fats in their diet to help them in brain development. And we need healthy fat to maintain that. So the kinds of fat that we, you know, fat in and of itself is not a bad word. Healthy fats are important. Unhealthy fats we want to stay away from. And that's the difference between the periphery and the aisles in the grocery store. So socializing, exercise, diet, what's next? The next thing I would put under the broad heading of safety. We need to make sure we don't get any injuries to our head. And so this is especially important as we get older, but it's true for younger people too. We want to do everything we can to reduce our risk of a fall. So, practically speaking, now we had a snowstorm here last night. The ground is icy. I want to be very careful walking on the ice so I don't slip and fall and get a bump to my head. We want to think about the floors at home, making sure there's nothing there that I can catch my foot on, trip on, stumble over. Um, so keeping the floors clear. And also, especially as we get older, not climbing up on things, a step stool, a chair, a stepladder, because when I go up off the ground, my risk of a fall increases dramatically. So I want to avoid the things really as as far as I can across my lifespan that are going to cause me to fall and get a blow to my head.

SPEAKER_02 17:27

Okay, so avoiding head trauma. What other suggestions do you have there for healthy uh brain development and maintenance?

SPEAKER_01 17:35

So one thing that I've been adding more recently with my patients is talking about the importance of a good night's sleep. Good sleep hygiene is vital to our health overall. You know, as we look at our sleep cycle, what happens to us while we're sleeping, it's actually a very active process while we're sound asleep. There's several cycles to our sleep process that we go through multiple times over the course of a night. So when we first fall asleep, that's considered stage one sleep. But then we go through stages of increasingly deep sleep down to stage four sleep, our deepest sleep. That's when the brain does a lot of its repair work, removing toxins, helping with connectivity. And then periodically during the night, we come up to a state that's just short of consciousness and being awake, called the stage of REM sleep. And that's where we have a lot of our very vivid dreaming happen. So the process of sleeping is going through that five-stage cycle again and again and again. And we want to make sure that we're getting a consistent night's sleep and not waking up during the night to interrupt that process. Because you one thing that happens as we get older, you know, first of all, we tend to have a shorter amount of sleep. The average adult needs about eight hours sleep, give or take an hour, but that can go down to six hours, average night's sleep for an older person. And if we're getting up to go to the bathroom or there's other kinds of sleep interruptions, we may be missing some of those important parts of the sleep cycle when the brain repairs itself. So one thing I always ask my patients when I'm doing a neuropsychology evaluation is how they're sleeping at night. Is it taking them a long time to get to sleep? Are they waking up during the night for one or more reasons? Are they getting up after a good refreshing night's sleep, or are they waking up too early? Because, you know, there are three kinds of insomnia. There's initial insomnia, trouble getting to sleep. Normally we should be able to fall asleep about 20 minutes after we turn the lights out, put our head on the pillow. But it can take people longer. Middle insomnia is that waking up during the middle of the night. And the third kind of insomnia is early morning waking, when we get up before our night's sleep is done. So I grill people on their sleep patterns and talk a lot about being consistent in our sleeping, going to bed about the same time each night, getting up about the same time each morning, including on the weekends. A lot of us make the mistake of staying up late on a Saturday or Sunday, and then we get up Monday morning and we start the week exhausted. And that's because we've thrown our sleep cycle off. And so we go to work tired. And when we're sleep deprived, we don't focus well, our energy is low, and our memory doesn't work as well. The first step in memory is getting stuff into my head so that I can remember it. If I have not been sleeping well and I'm overtired, that process doesn't work as well. And so I can feel like I have memory trouble when I'm tired, but it's the tiredness that's actually causing that difficulty at the first stage of memory. So the importance of getting a good night's sleep, I think, can't be overestimated. And if I have a patient who's having sleep trouble, I want them to see a sleep doctor. I want them to talk to their primary care physician. I want to talk with them about what their day is like. Are they having caffeine in the evening? Because if we have a cup of coffee after dinner, that caffeine can stay in our system a good six to eight hours. So I may still have caffeine flooding into my brain at midnight if I have a cup of coffee around five or six. Well, those types of things are important. And going back around to one of the other things that helps, when we exercise, we sleep better. So there are many things that really are kind of interconnected in in brain health. And when we're doing that, we tend to have better sleep, better overall health, better cognitive functioning across the lifespan.

SPEAKER_02 21:02

Yeah, I'm glad that you talked about sleep there because um I did a whole episode on sleep for people the audience members, if you want to go look for that one. Uh the whole episode is dedicated to sleep, and I think that sleep is an extremely underappreciated uh thing that we need for optimal health and to have the best life that we can have.

SPEAKER_01 21:27

Absolutely.

SPEAKER_02 21:28

Okay. Anything else to mention about this? So we've got socializing, exercise, safety, sleep. Anything else?

SPEAKER_01 21:37

I would just say one more thing about sleeping. And you know, I've read in the literature that in many ways we in the West have been sleep deprived since the late nineteenth century, which is when electric lighting became widespread in homes. You know, prior to that, how did we live? I mean, the world was lit by fire and by candles. And so more often than not, most of the human race would go to sleep when the sun went down and it got dark, and we'd get up in the morning when the sun came up. Electric lighting extends the daylight time. And so there's one school of thought that would say, you know what, we've been sleep deprived since about the 1880s, and we need to keep that in mind about making sure we get a long enough night's sleep and not stay up into the night when we should be sleeping.

SPEAKER_02 22:16

Yeah, good point. Well, that sounds like a quite a chronic problem then. I you know, and a hard one to, you know, one of the things that I talk about with sleep hygiene is really uh having a wind down period, you know, where you you know you kind of dim the lights, stop looking at devices, that kind of thing, maybe read a book that's like on paper, like a paper book or a magazine, meditate, pray, exercise, stretch, you know, something where you kind of like power down your mind.

SPEAKER_01 22:51

Exactly. Exactly. It's a process of winding down to get to sleep. And if you know, if I'm lying in bed watching an action adventure movie, I'm not gonna drop off to sleep as soon as the movie's over. It's gonna have me revved up and I'm gonna be awake a while.

SPEAKER_02 23:04

So one thing that you didn't mention, which I think is interesting, is like cognitive puzzles and exercises, crossword puzzles, word searches, wordle. You know, where does that fit in?

SPEAKER_01 23:19

Yes, I do talk to my patients about that, and here's where it fits. Are they good things? Absolutely. There have been functional neuroimaging studies done about how our brains are working in different kinds of activities. What gives us the most brain activity is the thing we mentioned before, socializing, talking to people. Our brains are not very active at the other extreme when we're watching television. Everything else falls somewhere in the middle. So puzzles, reading, word games, computer games, things like that. So what I often say to my patients is that you look at the activities, think about a scale where at the top is socializing, 100% brain activity, at the bottom is watching TV, everything else is somewhere in the middle. And so the thing to do, I think, is to look at the activities I have available to me and go with the one that gives me the best brain exercise. So if I can socialize, I want to do that. If I don't have the socialization opportunity, then I want to aim for those middle things. And for many of us, if you live in any kind of northern climb, the middle range things become more important during the winter when you know we're home for snowstorms or in the house more. Those things become important to do for brain activity and not just kind of have the fallback of sitting in front of the TV all evening. So they are important and they certainly do have a place, but we also want to keep in mind that that that range of things that give me good brain exercise. That's fascinating.

SPEAKER_02 24:42

So what why is it that socializing takes so much brain uh activity?

SPEAKER_01 24:49

Here's the first example. When you make eye contact with another person, you activate 70% of your brain. And so just by making eye contact with someone, then you add in conversation, memory, emotional life, things like that. That's what gets our brain activity up to 100%. So there's something about face-to-face human contact that really is the best brain exercise we have.

SPEAKER_02 25:12

That's that's amazing. So I think that um we are gonna get to this portion of the show where we have to talk about when things go wrong. And that's that's a shame because sadly things go wrong, and and you know, we we call it we call it dementia, and a lot of people use the word Alzheimer's. And I think there's a lot of confusion out there about you know, is is Alzheimer's just dementia? Uh is it just another word for dementia? Can you clarify that, please? Sure.

SPEAKER_01 25:48

Yeah, the the the term dementia is very common. It's actually not used in the uh the current nosology for um for cognitive difficulties. But dementia, as it exists, is a clinical term and and as a popular term, is is a descriptive statement. It means that someone's had some kind of decline in their thinking. It might be in their memory, their language skills, perceptual skills, reasoning skills. So it's just a statement that, hmm, something's changed. You know, a person was at a certain level and now they're below it. That's the first part of a cognitive diagnosis. The second part is to say, what caused that change? That second question is a really important one because that's where you get into the different kinds of medical conditions and illnesses that can cause that dementia, that decline. Alzheimer's is one of the things that causes that decline. It's the most common kind of neurodegenerative illness that's associated with aging, but there are many other things as well. People can have cognitive decline due to strokes and due to a whole bunch of other rarer genetic and neurologic conditions. But so you know it would be accurate to say dementia of the Alzheimer's type. The current terminology is to say not dementia, but what's called a major neurocognitive disorder. It means there's been a change in a person's thinking, some aspect of it that's not a manifestation of normal aging. You know, as we were talking earlier, as we get older, the normal aging change is a little bit of deficit retrieving facts, information. The neurocognitive disorders are more than that. So somebody with Alzheimer's disease has far more difficulty with their memory than someone who is aging normally.

SPEAKER_02 27:26

You know, what what are the signs of dementia? What you know, if you have a parent, well, you know, usually it's a parent, and you you see something that's like a little off. Like, what are the signs there?

SPEAKER_01 27:41

So the first signs are two things about that. In in rehab, you know this, and and in Neuropsyche as well, we talk about activities of daily living. There's two kinds of activities of daily living. There's the basic ADLs, activities of daily living, that are the basic things we do dressing, grooming, eating. Those things tend to stay intact across our lifespan. There's a higher level called instrumental activities of daily living. That's the more complex stuff we do. Financial management, cooking, we have to follow recipes, driving, all of our more complex decision making. If someone's developing a neurocognitive disorder, it starts to affect those instrumental activities of daily living. So people may start making mistakes and balancing their finances. They may start making mistakes when they're cooking. So they might leave out parts of a recipe. In terms of driving, the person may get lost while they're driving along a familiar route, or they may start to have some small accidents. So one thing I ask families is are there any dents and dings on your mom's car that are an indication that she may be not driving as well as she was? So any of those more complex kinds of activities, they are supposed to remain intact in the normal aging process. If they're not, that's really the big red flag that something is changing. And if you see some of those things changing, what what should you do? The first thing to do would be to talk with your primary care physician and say, looks like something's up. Uh you know, in in the neurology conferences that I attend about dementia, one thing that they've really been hammering away at in recent years is that if someone says they feel like their memory is changing, that has to be taken seriously because that statement could put someone in a higher risk category of developing a dementing illness. Once we hit about our mid-60s or so, our primary care physicians are supposed to do a short cognitive evaluation with us at our annual physical. So if there are some changes happening, the important thing is to get evaluated properly. And American Academy of Neurology, the psychiatry organizations, they they talk about four steps to that process. A standard of care evaluation. The first one is to have a medical evaluation done, to look at a person's overall physical functioning and say, is there any systemic problem in the body, liver malfunctions, kidney disease, vitamin deficiencies? Is there anything there that might be causing memory trouble? The second thing is, you know, in our annual physicals, we have blood work done, and we're mostly concerned about a cholesterol when we do that. But there are some additional types of lab work that are done when there's a question of, say, memory loss, looking at vitamin deficiencies, especially things like B12, someone who has a vitamin B12 deficiency can have major memory difficulty caused by that vitamin deficiency. So medical available, some additional blood work. The third thing is a neuroimaging study, a CAT scan or an MRI. And the purpose of that is to rule out any potential structural causes in the brain that might be accounting for cognitive change. Has the person had a stroke? Is there a tumor or a mass in the brain? Something that's not supposed to be there, it's impacting a person's thinking. And then the fourth part is a neuropsychology evaluation. And what that is, it's a it's a very detailed and more extensive mental status examination to say, in all the major areas of cognitive functioning, executive skills, language, memory, visual spatial skills, are things where they're supposed to be for a person at a given age or not? And if not, what's causing that change? So if someone is actually experiencing cognitive changes, if you do those four steps and go through that process, if there's something there, it's highly likely it will be found, it'll be specified, and then that will then say what can be done to help with it. Is there something that's reversible? Is there a systemic illness in the body? Is there something going on that a medical intervention will reverse? You know, one example is as folks get older, is someone can have a urinary tract infection. And someone who gets a UTI can go from being awake, alert, doing fine to being extremely confused, hallucinatory, and all kinds of problems. When the urinary tract infection is treated with antibiotics, all those symptoms go away and the person comes back to normal. So it first of all underlies the importance of our body and its relation to the brain. And secondly, the kind of investigation that ought to be done to say if there's a problem, what is it, and then what can be done to help with it? Either to reverse something, or if it is something more serious, to do everything possible to reduce any cognitive decline that might have already started.

SPEAKER_02 32:10

Yeah, what you mentioned there about UTIs, I've seen so many times in my clinical career, uh, it's remarkable how how quickly somebody recovers their their cognitive abilities once you treat that infection. Another thing that's really common is dehydration in the elderly.

SPEAKER_01 32:29

And you know, the first thing I want to say about dehydration is we also have to think about it in the winter. You know, it's it's easy in the summer we're warm, we're thirsty, we drink more water, but an elderly person can get dehydrated in the winter too. So it's important to keep an eye on our fluid intake year-round because dehydration affects every organ in the body, including the brain. So if someone's not getting enough fluids, and that can often cause cognitive changes. And so sometimes people wind up in the emergency room and they do all the work up and they do scans and things like that, and the end result is you dehydrated, drink more water.

SPEAKER_02 33:03

Yeah, and once again, I've seen that many times in my career where you would give somebody an uh IV fluids and they would suddenly become themselves again. It's it's really quite amazing to see. So, what you're saying is that if somebody uh sees some changes in themselves or a loved one, you go to your primary care doctor and start this evaluation looking for uh treatable, reversible things. And then if you find them, then treat them, of course. What if they don't find anything treatable or reversible?

SPEAKER_01 33:39

What what then? So, you know, I mentioned those four steps: medical evaluation, blood work, neuroimaging, neuropsychology evaluation. If there's a medical cause that's reversible, you go to your primary care doctor, that's done. All you need is step one. You don't need to go through those additional stages. So it may just be a phone call to the doctor. You know, if someone's starting to have confusion suddenly and they're not typically confused, that can be the sign of a urinary tract infection, brewings. You pick up the phone, you call the doctor's office, they may want to see you, or have you go to urgent care, get you on an antibiotic, and that short circuits the whole process. You don't have to go further. If that workup is done and nothing is found physically in the body that might be causing a trouble, a problem, that's when you go to the additional stages, looking at blood work that may be pointing to some difficulties, having a neuroimaging study, having a neuropsychology evaluation. So one does not automatically have to go through all four of those steps. They're in that order so that if something physical is going on in the body, you deal with that right away. And if that solves the problem, great. If it doesn't, then you go to steps two, three, and four and say, okay, where in this process, which among these things is causing the trouble? And is there something you know medical that hadn't been detected that can be treated, or is there something a neurodegenerative process, something in the brain of physical illness that's causing neuronal destruction, interruptions in connectivity in the brain that has to be identified and treated insofar as it can be?

SPEAKER_02 35:06

Well, thank you for clarifying that. So it's a stepwise process, and you don't have to go through all four steps. Right. But but what happens if you do? You go through and you get you end up at step four, which is a neuropsych evaluation, and you've it's found that you have multiple issues with your cognition, probably pointing in the direction of Alzheimer's. Is there anything that can be done for at that point?

SPEAKER_01 35:31

Yes, there is. And you know, many folks in in the older generations that I work with, folks in their 80s and 90s, that they hear the word Alzheimer's and they automatically think it's a death sentence, and they immediately go to what people look like in the end stages of the illness. And that's not the case anymore. Alzheimer's is the most common cause of cognitive dysfunction in the elderly. The second most common cause is having small strokes in the brain. That's referred to as a major neurocognitive disorder due to vascular problems. The third most common kind is just the combination of those two. Then there are other rarer conditions like Huntington's disease or other illnesses that you don't see very often, even in a specialty clinic, but that cause cognitive change as well. So chances are if someone is having especially memory decline beyond the normal aging process, more often than not, that's going to be caused by Alzheimer's disease. Going through that four-stage process can identify that. And if it is Alzheimer's disease, and there are millions of people in this country and tens of millions of people worldwide who have it, the things we talked about earlier: socializing, physical exercise, healthy diet, safety, getting a good night's sleep, those are the non-pharmacological interventions for Alzheimer's. There is an additional thing in that there are a group of medications that have been around since about the 1990s that can help slow cognitive decline when Alzheimer's disease is present and try to keep someone's memory functioning where it is at the time of diagnosis. And the good thing that's been happening in recent decades is that primary care physicians are referring people for these that four-step evaluation process sooner rather than later. You know, 20, 30 years ago, still, it was the case that if you told your primary care doctor, I'm having some memory trouble, they kind of brush it off and say, Oh, you're just getting older, don't worry about it. It's now understood that if someone makes that statement, that's the red flag to begin the evaluation process. And as a result of that, something like Alzheimer disease is caught very early in the early stage, and all of those interventions are geared toward keeping somebody there functionally so it doesn't advance to the middle or the late stages of the illness.

SPEAKER_02 37:31

So you're saying that we can slow down the progression of the Alzheimer's?

SPEAKER_01 37:36

It's an important distinction to make here. The illness process continues, but functionally, someone can stay much higher functioning, potentially for the rest of their lives. What the medications do is enhance the functioning of a neurotransmitter in the brain. I mentioned before talking about neurons. Neurons aren't physically connected. There's a teeny tiny space between them. And small molecules called neurotransmitters traverse that distance for neurosignaling. In Alzheimer's, for example, the brain isn't making enough of those neurotransmitters, particularly one called acetylcholine. What the medications do is enhance the presence of acetylcholine at the synapse. So even if there's a degenerative process happening, there's more neurotransmitter available. So functionally, memory can stay very similar to where it is when it's first diagnosed. Okay.

SPEAKER_02 38:26

All right. Well, thank you for clarifying that. So we don't actually slow down the progression necessarily, but we slow down how it looks and how it affects you so that you are still able to be more functional as you age.

unknown 38:42

Yeah.

SPEAKER_01 38:42

Yes, and there's massive amounts of research being done on underlying causes, you know, to figure out why one person gets Alzheimer's and another doesn't. Why does somebody with no family history suddenly get Alzheimer's? Why does somebody with a long family history not get it? Um, you know, there's a class of people researched very actively across the world called super agers. And those are persons who get into their 80s and 90s, but their memory functioning is like it was when they were in their 50s or younger. You know, what what how are these people different genetically, lifestyle across the board from folks who even are aging normally who will start to have some of those retrieval deficits? So there's a lot of research being done. There is a, I will mention there is a new class of medications that just became available in the past couple of years. They're called beta amyloid clearance agents. So one of the things that happens in the brain in Alzheimer's is plaques get built up outside the neurons. The beta amyloid clearance medications can clear away those plaques, but they're they are a two-edged sword at this point. They can make a difference in clearing the plaques. They may give some brief respite of a few months from cognitive decline, but then that continues on again. And if someone is getting one of those kinds of medications, they're only available as IV, you know, intravenous. The person has to have one or two IVs a month. There are also another number of other things that happen. Like a person has to have regular brain neuroimaging and cognitive evaluations. The risk factors, which are fairly rare, but still there with these medications, that they can cause brain bleeding and brain swelling. So those are potentially deadly side effects if they're not picked up. So there is now a medication available that will directly attack one aspect of the disease process, but it's not without risk. And it's only available to folks who are in the very early stage of Alzheimer's disease. So here's the second class of medicine, but one has to approach it, I think, rather cautiously.

SPEAKER_02 40:33

Yeah, yeah. And it's important that uh the listeners realize that, you know, this is not a recommendation to run out and get that one of those meds, but talk to your primary care doctor uh if you have any questions. Um so I think that the that's all that we have time for today. You know, one thing that I would like to dedicate a future episode to is you know, how do we care for somebody who does have it more advanced um cognitive impairments? But we'll save that for another time. Jim, I um I want to give you a chance to to sum up. If you had you know one more thing to say before we close this topic off, is there anything you'd like to share?

SPEAKER_01 41:19

The one thing I'd say for both healthy aging and for folks with cognitive issues is to socialize. That's the most important thing.

SPEAKER_02 41:26

Yeah. So I and that's a that's a real theme across the Life and How to Live It podcast is uh the importance of connecting with other people. It's it's it's great for your quality of life and for your health and for your brain health. Yes. So so, Jim, before we close out the episode today, I want to ask you a question that I ask every guest on this program. And the question is if you had the ability to put a message on a billboard in your town, so this would be a billboard that a lot of cars go by every day. So, you know, you'd get that message out to people. What would your message be?

SPEAKER_01 42:08

I think one thing I think about putting on there, because it's nice and short, is that the British novelist Ian Forster uh wrote a novel called Howard's End, and it begins with just a two-word statement on the first page. Only connect. That touches on what is really the most important thing, the cognitive health, emotional health, and all above, having connections with other people. That's what keeps us healthy and happy and a thing that we should all be looking for and working on creating and maintaining relationships. If we connect with others, we tend to do better overall.

SPEAKER_02 42:42

I love that, Jim. That's a that's a short and sweet message. Only connect. So imagine that as you're listening to this show and you're in your car, you see a billboard. That would be your message from Jim. Only connect. Well, thanks again for being on the show. Um this is very informative, and um I'd love to have you back to talk about some of the other interests that you have. Sure, I'd love to. Yeah. Well, thank you all for listening to today's episode of the Life and How to Live It podcast. Until next time, so long. That's all for today's show. Thanks for listening to the Life and How to Live It podcast with Dr. Rondo. If you enjoyed today's show, please subscribe and leave a review. See my show notes to find out more about the show. And remember, life is not a dress rehearsal. Until next time.