Jeremy Nobel (00:01):
There's no question that loneliness is a risk factor for cognitive impairment, even dementia. But also as people have cognitive impairment, it changes how they make sense of the world, and their world becomes smaller. They lose confidence in navigating the world. And so you start entering the risk of a cycle where the loneliness then increases cognitive impairment. Cognitive impairment then increases a sense of risk of navigating social situations. People withdraw more.
Opening (00:30):
Welcome to Brainstorm by us against Alzheimer's, a patient center, nonprofit organization. Your host, Merrill Comer, is a co-founder, 24 year caregiver and Emmy award-winning journalist and the author of the New York Times bestseller, slow Dancing With a Stranger.
Meryl Comer (00:47):
This is Brainstorm and I, Meryl Comer I on the priorities of the 21st US Surgeon General is the issue of chronic loneliness, which he calls the silent epidemic that increases the risk for heart disease, mental health issues, and even dementia. Vice Admiral, Dr. Vivic Murti says, we must regain what is a society. We've lost the consciousness of connection. Our guest today is Dr. Jeremy Nobel primary care physician, public health practitioner with faculty appointments at the Harvard t h Chan School of Public Health and the Harvard Medical School. He is the founder and president of the Foundation for Art and Healing. Dr. Nobel, welcome. Thank you so much for joining us.
Jeremy Nobel (01:36):
It's a pleasure to be here with you. Meryl,
Meryl Comer (01:38):
The early focus of your foundation's work was on Trauma in children post nine 11 and the healing linkage with the arts as a celebrated poet and photographer. Was that focus in intuitive on your part or was there already emerging science? Looking at how the brain responds to the arts,
Jeremy Nobel (01:57):
What got my attention after nine 11 was a museum exhibit that was in the summer after nine 11 of art that kids made who were dealing with their own experiences of nine 11. They were invited by psychologists who were helping these kids, many of whom were struggling with acute trauma response. They had difficulty concentrating in schools, sleep disturbances, emotional liability, outbursts of emotions, and the very simple invitation to draw what's on their mind and then have a conversation help them get much better, much faster across race and class lines. I thought that was so important. It meant that there's something in the brain that happens when we link imagination the invitation to recall something with the invitation to express something creatively and then have conversations. And I thought that was too important to and was not central to my academic work. So that's why I chose the path of a nonprofit foundation, and we've been at it for almost 20 years now.
Meryl Comer (02:57):
The signature initiative of your foundation for Art and healing is Project UnLonely. It's also the title of your latest book on healing, our Crisis of Disconnection. Does the science show that isolation and loneliness influence both our health and mortality?
Jeremy Nobel (03:16):
Well, there's a growing body of evidence that loneliness won't just make you miserable, right? It's a leading risk factor for depression, addiction, suicidality, self-harm, but it will kill you. There's compelling evidence that it reduces life expectancy by 30%, increases risk of premature mortality by 30%, increases risk of heart attack or stroke or death from either by a similar amount, 30% increases risk of dementia by 40%, type two diabetes by 50%. So it really comes down to this recognition that loneliness won't just make you miserable, it will kill you. And I think that growing recognition has led to an incredible variety of efforts to increase awareness about loneliness, to reduce the stigma that surrounds it, and find a variety of ways to make people more connected.
Meryl Comer (04:14):
As Alzheimer's advocates, we're forced to fight the stigma of the diagnosis and public misperceptions surrounding the disease. What is the stigma around loneliness? Is it tied to self-esteem and is it subjective?
Jeremy Nobel (04:30):
Loneliness as a phenomenon is 100% subjective. Loneliness is really the self-perceived gap between the relationships, the social relationships you would like to have, what you aspire to and what you feel you experience. And it's also very much influenced by cultural expectations and norms. Where do these expectations come from? Where do the self-assessments come from? So the paradox is while we have a crisis of loneliness, in many ways it may be under our control and societal control. As we change the narrative, change the story around loneliness, become more aware of it, recognize that it's not our fault if we're lonely in many ways, it's the result of certain societal forces and influences and the way we've been trained culturally to think about loneliness. And as you point out, often it is related to low self-esteem or lack of self regard that keeps people from moving forward, connecting with others and having exactly the situations and experiences that would make them feel more connected and less lonely. And that's what we're trying to do something about with Project UnLonely.
Meryl Comer (05:35):
On a population level, has aging and mild cognitive impairment exacerbated the loneliness effect.
Jeremy Nobel (05:43):
It’s a two-way street there. The relationship, there's no question that loneliness is a risk factor for cognitive impairment, even dementia with these estimates of 40 to 50%. But also as people have cognitive impairment, it changes how they make sense of the world. Their world becomes smaller, they lose confidence in navigating the world. And so you start entering the risk of a cycle where the loneliness then increases cognitive impairment. Cognitive impairment then increases a sense of risk of navigating social situations. People withdraw more. So we believe the way to intervene on that is to drive the cycle the other way. So for instance, if someone has mild cognitive impairment, not to wait until they say they're lonely, or even ask them if they're lonely, but assume that there'll be some degree of loneliness and treat social connection amplification as a therapeutic goal in the same way we treat diet, exercise, and sleep, to include that as the basic requirement for health and wellbeing as a primary care physician, I think that could be helpful to many people because otherwise you have to wait for someone, first of all to recognize something that's stigmatizing and difficult to recognize, but then also have the courage to ask for help.
Meryl Comer (06:58):
Issue to be able to ask for help is <laugh> always present. Informal caregivers today provide about 75% of long-term care in this country. As a long-time caregiver, I can attest, we're treated as invisible and not supported by the system, and we are also isolated with our loved ones in the disease. So I'd like you to put on your primary care hat and help me through this. How do you begin to fix that situation
Jeremy Nobel (07:25):
By going early with the assumption that everybody in a caregiving role is at risk for social isolation and loneliness. I'm not saying they all have it, but they're all at risk for it. We know that from research and we also know that if you begin early encouraging people as new caregivers, for instance, with people with dementia, to do a few things. First of all, to recognize that they're on a rough journey as a caregiver for someone with dementia, you know that from your personal experiences, but often in the beginning stages, people so filled with love and concern for their loved ones sort of feel that they can kind of self-sacrifice their way to success. Now, they may not feel that consciously, but they say, well, you know, I can get through this. They don't ask for help. And they also sometimes feel that they're alone. They fail to have the benefit of even simple conversations with other people. They could share their stressors with what keeps them up at night and recognize that there's a whole community of people out there for the exact reason you say because it's become so common. What's less common are the opportunities and the channels to have honest, authentic, supportive conversations between caregivers so that they can get the support from that community that they so richly deserve.
Meryl Comer (08:37):
More than three quarters of people with Alzheimer's experience agitation as a symptom of the disease. As a caregiver, you avoid social engagement, isolate with the patient, protect their dignity, and live in fear that such an episode will happen again. What advice do you have for caregivers when trying to override the isolation effect?
Jeremy Nobel (09:00):
Of course, this is part of the pain of being a caregiver for a loved one who's going through these kind of changes in personality outbursts of various types, difficulty on the behavioral side. This is very painful to watch. It's painful to have conversations with other people about you do wanna protect your loved one, and yet at the same time, how do you do that? And so this is very challenging as you know. And then the question is, success has to be driven in multiple channels. So the first which we're beginning to see is people talk more about it, which takes a lot of courage. But in sharing those stories, it begins to normalize the situation so it's easier for other people to talk about it and get the help they need. It's also increases the compassion and awareness that society in general has for dementia.
Jeremy Nobel (09:48):
It's poorly understood some of the more dramatic forms of dementia, which often are very associated with frontotemporal lobe dysfunction and other kinds of emotional outbursts. These are terrifying to people who don't understand what it's about. It's terrifying and kind of disquieting even when you do know what's going on. And I think that being able to share stories and feel that you're not the only one dealing with these circumstances is maybe one of the most important things we can do until there's much more effective treatment. There's been some promising progress. I think the general sense is we still have a long way to go. So until we can achieve full medical relief from Alzheimer's and similar cognitive challenges, I think the biggest thing we can do is operate together rather than alone. In navigating those challenges,
Meryl Comer (10:36):
Dr. Nobel, we're at a critical point in the early diagnosis of dementia. How do you normalize the status of those diagnosed with mild cognitive impairment? Because currently once diagnosed, they're also marginalized professionally and socially.
Jeremy Nobel (10:53):
I hope this isn't too provocative a statement, but there is evidence that in early stages of cognitive impairment, mild cognitive impairment, very robust and even aggressive social connection activities, including introducing the arts, can stabilize or reverse the mild cognitive impairment. Now, it's not surprising because of the medical industrial machinery and the amount of money involved that there's a sense that, okay, well the optimal thing to do is begin using that armamentarium of medications earlier. And there may once careful studies are done, show that there's a good strategy in doing so. But I hope we don't overlook the application of a similarly effective armamentarium that doesn't require medication, but does include creative engagement with people, engage a chance to find and share stories, a chance to enjoy and behold the beautiful art of music and visual art as a way to forge social bonds that we know are neuroactive and in some cases neurologically stabilizing. So it's not an either or, but it would be a shame if we ignore the obvious opportunities to use Neuroaesthetics and the progress made there. And just the simple evidence that social connection can be stabilizing for mild cognitive impairment as aggressively as we can.
Meryl Comer (12:10):
What are your metrics for success?
Jeremy Nobel (12:13):
Mission at the foundation to engage and use creative expression to improve health and wellbeing for individuals and communities, you immediately recognize that there are many ways to measure health and many ways to measure wellbeing. Some of the most powerful ways are actually attitudinal. How do people think about their own health and their ability to manage? Do they have confidence? They can navigate their various challenges in health and wellbeing? And so we see some very positive increases in that in the participants in our programs. Now, we also ask them whether they have positive health experiences and that are they less lonely, those kind of things. We see positive benefit in that as well. I am quite confident and we're starting to see rigorous research demonstrate this, that well-designed studies that move longitudinally to show how creative expression as a way to be better in touch with yourself and others can change positive health behaviors like medication adherence, like engaging with the health system in a significant enough way to decrease morbidity and mortality in a population.
Jeremy Nobel (13:18):
And that would be a fantastic endpoint to be able to demonstrate. We're just at the early stages of that right now. What I'm really hoping people take this as, and I engineered the book for this, is Design Your Own Project UnLonely. We're just giving you the principles or that's what I'm trying to do. And also, many of those people I reach, I hope, do work within the institutions that need to change and become connection oriented. Health systems are really, really uninviting places they were before the pandemic, and it's worse now for a variety of reasons. They're understaffed, they're stressed out, the clinicians are burned out. I can't know this for sure because I haven't done the research, but I suspect medical errors are up just because that's what happens. And you know, I think we've gotta take a step back and designed some of these basic systems from the ground up with human connection being at the center. I think that would actually transform many of them.
Meryl Comer (14:10):
Our guest has been Dr. Jeremy Nobel, founder and director of the Foundation for Art and Healing, and author of his new book, project UnLonely Healing Our Crisis of Disconnection. That's it for this edition. I'm Meryl Comer. Thank you for brainstorming with us. Our team is on a mission to help you stay up with the latest scientific breakthroughs from new therapies to technologies on early diagnosis and personal brain health advice from well-known experts using an equity lens that promotes brain health for all. Now we'd like to hear what's on your mind, what are the topics and guests you'd like to hear featured on brainstorm? Send your comments to BrainStorm@usagainstalzheimers.org
Closing (15:03):
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