We've all forgotten where we left our car keys, or the name of an old acquaintance. It's not uncommon to develop some memory issues as a part of the aging process. At what point should be we concerned that these "senior moments" are a symptom of something serious, like dementia?
Host Jonathan Fialkow, M.D., chief population health officer for Baptist Health, welcomed Patricio Espinosa, M.D., chief of neurology at Marcus Neuroscience Institute at Boca Raton Regional Hospital to the podcast to explore memory disorders and dementia.
The discussion covered diagnosis, prevention, treatment and the facts about supplements advertised to aid memory function.
This podcast contains excerpts from Baptist Health's Resource Live program.
We've all forgotten where we left our car keys, or the name of an old acquaintance. It's not uncommon to develop some memory issues as a part of the aging process. At what point should be we concerned that these "senior moments" are a symptom of something serious, like dementia?
Host Jonathan Fialkow, M.D., chief population health officer for Baptist Health, welcomed Patricio Espinosa, M.D., chief of neurology at Marcus Neuroscience Institute at Boca Raton Regional Hospital to the podcast to explore memory disorders and dementia.
The discussion covered diagnosis, prevention, treatment and the facts about supplements advertised to aid memory function.
This podcast contains excerpts from Baptist Health's Resource Live program.
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Dr. Jonathan Fialkow:
Welcome back, Baptist HealthTalk podcast listeners, I’m your host, Dr. Jonathan Fialkow, I’m a preventative cardiologist and certified lipid specialist at Miami Cardiac and Vascular Institute, and chief population health officer at Baptist Health South Florida.
It is not uncommon to develop some memory issues as part of the aging process. The question is: when should you be concerned that memory lapses or confusion are signs of a more serious problem like Alzheimer’s disease?
Memory Loss and Dementia was the subject of a recent episode of Baptist Health’s Resource Live program, which I had the pleasure of hosting. My guest was Dr. Patricio Espinosa, chief of neurology at the Marcus Neuroscience Institute at Boca Raton Regional Hospital, which is part of Baptist Health.
We talked about symptoms, treatment and real-life strategies to keep our brains active and healthy. Let’s listen in:
Dr. Jonathan Fialkow:
Patricio, let's start with a little level set. We throw the term around dementia, it's something that obviously people are very fearful of in themselves or their loved ones. Can you describe or explain what dementia actually is from a medical standpoint?
Dr. Patricio Espinosa:
Always my patients are asking me, "Do I have Alzheimer's? Do I have dementia?" Sometimes dementia has a negative connotation. However, dementia is a general word that basically describes cognitive changes over time. The number one cause of dementia is Alzheimer's, which occupies about 75% to 80% of the cases of patients with dementia. Then we have other causes of dementia such as dementia with Lewy bodies, frontotemporal dementia, dementia pugilistica. Another one that is very common actually here in South Florida is dementia due to stroke, we call it vascular dementia. So dementia is a generic term, and then there are different types of dementia that can be caused due to different neurological illnesses or insults.
Dr. Jonathan Fialkow:
From the average person who experiences something, how do we address if I forget where I put my keys or, again, someone's name I just can't remember, but you'll arguably remember it later, these senior moments, so to speak. What would be signs or signals that something someone's experiencing or a loved one is experiencing warrants a little bit more further attention? What could be considered normal parts of aging and normal parts of people's behavior?
Dr. Patricio Espinosa:
So what we look definitely for is for a change. A change in the cognition. We all forget some little things here and there. Like we forget where we place the keys, sometimes we forget a little bit where the car was but we find it. When we recover that memory that was missing, problem is okay. We all have those little problems. However, when we see a change in the normal cognition of somebody, so let's say somebody becomes very repetitive, they tend to ask the same question over and over again. So are we going to doctor today? Yes, we're going to doctor today at 8:00. And then five minutes later, again, the same question over and over again. So these type of memory problems that need a little bit of help to recover. So those are warning signs
Most people normally know what's today's date or the year or the season, some basic orientation facts. When we start seeing a change in that normal cognitive behavior is when we have to be worried and concerned and seek medical attention. Not everything that causes memory loss is dementia or a neurological condition. There are some other conditions that we can treat and can actually revert. So that's part of the workup that we do as neurologists is to make sure somebody doesn't have a reversible cause of memory loss.
Dr. Jonathan Fialkow:
So, someone's now coming to you concerned that they may have some early signs of dementia. How do you evaluate them? What processes do you go through to both assess, and then we can get into treatments?
Dr. Patricio Espinosa:
We typically require a caregiver or somebody that knows about the normal behavior of the person to give us some feedback. So it's very important for the memory assessment to bring somebody that knows you or has experienced what the memory problems are. Once we do that, we collect a lot of information about the history, when the memory are lacking, what are the situations that have caused the memory loss? For instance, we had a patient that was driving the car here in South Florida and was going to a doctor appointment and next thing, the patient knows, he's in Key Largo. So things like that. So that's a major event.
We'll also look at medical conditions. Sometimes patients may have chronic conditions. Sometimes depression can mimic also memory problems. We call it slow dementia. We also look at the medication. There's some medications that we call antcholinergics that may be associated with cognitive changes. We also do look at the social history. Maybe sometimes patients drink a little bit too much, there's a dementia actually related to alcohol. It's called alcohol related dementia. We also ask about the family history. We know that some patients have a higher risk of having dementia if they have close relatives with dementia illness. And then after that, we go into a physical neurological examination. And within the neurological examination, we do a cognitive assessment, basically where we test the memory in multiple domains. Orientation, date, time, we give patients a few words to recall. And in that way, we have an idea where the memory and the status of the cognition of the patient is.
We’ll typically order brain imaging, preferably an MRI of the brain. Why is it important to get an MRI of their brain? For a couple reasons. One, because there may be a tumor or a mass maybe pushing on their brain and mimic dementia. We have seen this in practice multiple times when patients may have these big frontal tumors that can cause cognitive changes that mimic a neurodegenerative condition. Where you remove the tumor, patients improve dramatically, actually. Also, too, here in the center, we have an MRI with a software that help us measure the volume of the memory centers and compare them to a norm. In that way, we can tell objectively if the thinning of the brain that we see to a certain extent normally as we age is normal for somebody's age in comparison to a norm. So we have that assessment here too, which we typically do in neural patient with memory problems.
Dr. Patricio Espinosa:
And then we also will do some routine workup looking for reversible causes of memory loss, such as hypothyroidism, B12 deficiency, autoimmune disorders such as vasculitis and others. So we typically, and always as a neurologist here and we teach this to our residents, we want to make sure when we diagnose somebody with a dementing illness that we have the right diagnosis and that we're not missing something that can be treatable or reversible. So that's very important before we commit to somebody for a life diagnosis.
Dr. Jonathan Fialkow:
Are there other symptoms besides forgetfulness that we should be alerted to?
Dr. Patricio Espinosa:
Depending on the type of dementia, there are going to be different symptoms. For instance, there another condition called dementia with Lewy bodies where patients can have fluctuation in their mental status. It can be good for a moment, then they become completely confused. They can have a little bit of Parkinson's-like symptoms such as rigidity, tremor, and hallucinations, but this is different than Parkinson's. While patients with Parkinson's initially present more with tremor, these other patients have other features. So each type of dementia has a little bit of different features that can help diagnose and actual prevent it. Somebody had a stroke, let's say. We want to prevent the cause of a stroke so there will not be more harm to the brain. So it's very important to classify and to know the etiology of the illness so you can treat it appropriately. And then sometimes, if there's something lacking like B12, we can replace it and make our patients go back to normal.
Dr. Jonathan Fialkow:
So again, speaks to that individualized, customized approach, comprehensive evaluation for someone. And the change in the person's behavior, the change in their condition would warrant the evaluation to be expedited. In your practice, so clearly it's anecdotal, of the patients referred to you for a dementia evaluation, how frequently do you find a condition, hypothyroid, vitamin deficiency, et cetera, that's reversible?
Dr. Patricio Espinosa:
About 10% of the times.
Dr. Jonathan Fialkow:
Okay, so not insignificant.
Dr. Patricio Espinosa:
No, but it's significant because we're a big referral center. So when we get patients referred here, they're having already worked out by their primary care doctors or internists. So we get patients who have been already brought to the attention of other colleagues and they come here for confirmation of their symptoms.
Dr. Jonathan Fialkow:
So thyroid, medications, other conditions, they would have been determined before they got to you from those numbers. Okay. How about can you elaborate a little bit? You mentioned very cogently at the onset of this program Alzheimer's versus other causes of dementia. And Alzheimer's being the most frequent cause of dementia, let's spend a little time on that. What makes Alzheimer's unique? Are there symptoms or treatments? Are there symptoms that might define Alzheimer's? And then we can talk a little bit about how you approach the patients who have Alzheimer's.
Dr. Patricio Espinosa:
We know that the main risk factor for Alzheimer's is aging. So here in South Florida, as you know, is a prime place for retirement. And we know based on epidemiological studies that at age 65, about 10% of the population will have this condition. As we continue aging, when you get to your ninth decade of life, it's estimated that actually 50% of people will have this condition. As you know, it's estimated that in the US, there's about five million patients with Alzheimer's and probably over 25 million in the whole world.
Dr. Patricio Espinosa:
Alzheimer's, the classic Alzheimer's, is characterized by forgetfulness. The classic one, we call it the amnestic type, where patients will have problems remembering things that they did in the morning or the day before or in the last week or two. They don't remember that they attended a birthday party over the weekend and they have to be reminded about it. However, at the same time, you ask them what were the classmates from elementary school, they may name 10, or they may name an event that happened 20 or 30 years ago. So the classic case of Alzheimer's initially starts with forgetfulness due to events that happened recently, what we call the short-term memory loss.
Dr. Jonathan Fialkow:
When you have a patient you evaluate comprehensively and you come with the Alzheimer's diagnosis, what are current medical treatments? And what do you see as coming down the pike to be able to help us in our assessment and treatment of patients with Alzheimer's?
Dr. Patricio Espinosa:
Yeah. So currently, we have two treatments approved for the treatment of Alzheimer's. There are two classes of medications that we use. Ones are called acetylcholinesterase inhibitors. One is very well used in practice called donepezil, the other one is called rivastigmine. And there's a couple more. And also NMDA receptor antagonist, which is Memantine. These two medications are the two medications that we currently have available for the treatment of this condition. These medications, through the data, have shown to decrease the speed of decline or the memory loss. Unfortunately, to date, there's no medication that can revert, or for that matter, this is in parentheses, improve the symptoms.
And I would like also to highlight the fact that, unfortunately, there are all these advertisements about all these vitamins, supplements. I don't want to say any names in particular, but all those things have not been shown to be effective, have not been shown to decrease the risk of Alzheimer's or to treat any memory problem for that matter. So I will try to avoid them. They are very expensive, very costly. And sometimes, these medications can also be toxic because some of them has tremendous amount of vitamin B6, which can cause toxicity. So I will tell all of our patients and people in Facebook today not to take any supplement unless it's prescribed by a clinician.
Dr. Jonathan Fialkow:
Let's talk about some preventative strategies. As a cardiologist, we certainly deal with the cardiovascular risk factors, the metabolic conditions which lead to vascular disease. And you did note vascular dementia is a significant frequent outcome on people with these vascular components. What do you both educate and what do you tell people or family members of patients, what can we do to kind of keep our brain agile to try to avoid these types of clinical outcomes of dementia?
Dr. Patricio Espinosa:
Yes. So the prevention of cardiovascular disease is very important for the brain and for the prevention. Actually, we think that we can prevent dementia by treating cardiovascular disease and high blood pressure. There has been data that shows that if you treat hypertension, not only you prevent a stroke, but also you prevent harm to the brain. And that can be not only protective, but it can also prevent these disorders. So there's so much strong data that tell us that if we control hypertension, hyperlipidemia, diabetes, we don't smoke, all of these things that are good and important for the overall health of the heart, of the brain, of the kidney, of your lungs is going to have a positive impact in the brain.
So what you, Jonathan, do as a cardiologist, we preach the same thing for in neurology because we think that it's very important to have a healthy body. You have to have your weight under control, you have to exercise every day, at least 30 minutes or walking. All of these things that improve your overall health will have a very positive effect in the brain. In addition to that, there's data about the Mediterranean diet, which has been also shown to have a protective effect and preventive of dementia and memory loss. So this diet, which is basically lean meats, fish, a lot of vegetables, small amounts wine, a lot of olive oil, have been shown to be actually protective. And that's what we encourage our patients to do.
Dr. Jonathan Fialkow:
As you say, they actually, some refer to Alzheimer's as type three diabetes, similar to some of the risk factors that lead to that vascular and then inflammation with [inaudible 00:25:45]. And the diet is very important, which is to avoid the processed foods, eat foods in their natural state, try and keep your weight under control. So well said. What about exercising your brain? It's a term we use quite often. Is that really beneficial? Is there something to doing puzzles and crosswords and reading and whatnot?
Dr. Patricio Espinosa:
We encourage our patients to do activities, to engage in things, to attend parties, to go to book reviews, to go to seminar courses. Here in Boca Raton, the communities here, they have community events. So to be engaged and to do exercise, to go and walk with friends, to be part of all of these activities that will involve some critical thinking. Also to play cards. All of these work. Unfortunately, there's not one thing better than the other. It also goes too to some of these other things that people advertise that, "Do this thing. It may help you remember to do these other things." Nothing has been shown to be 100% effective, but what we'd recommend is patients to be engaged. Engage in life, enjoy life, read, watch, go with people, be in activities, be a part of your community, help others. All of these things are very important.
Dr. Jonathan Fialkow:
Sleep. Sleep is such an important component of our body's health. We don't think of it that way. We think of it just the absence of being awake. Is there a relationship between sleep disorders or proper sleep patterns and the risk of dementia?
Dr. Patricio Espinosa:
Yes. Yes. There's links between them too. Too, as a risk factor, some patients can have some sleep disorders even before they develop the memory illness such as REM sleep disturbance, which is a very typical thing. But too, patients that don't get enough rest is very important. The average number of hours, depending on the person, is seven hours. Some people can sleep only five, some people need nine, a teenager may need 10. It depends. Another important topic that I would like to highlight and that we in the memory disorders world are working very hard is for our patients to avoid taking benzodiazepines and medications that work like benzodiazepines, such as Ambien or (inaudible). All these medications, they have been shown actually to increase the risk of memory loss. Moreover, studies have shown that sleep hygiene, which is to have a good behavior when you go to sleep, is as effective as taking a benzodiazepine at night.
So healthy and normal sleep is without a medication. Taking a benzodiazepine or benzodiazepine-like medication at night can prompt people to dementia, can lead to falls and to accidents. So in my practice, I have move away from them. I don't prescribe any of those medications to any of my patients specifically for this risk factor. And what I encourage them is to go to sleep at the same time. When they go to sleep, make sure there's no lights that are disturbing their normal sleep. I give them advice on at what time to wake up. And if they are not asleep, not to stay in bed looking at the ceiling or looking at their phone. Things that are very well known, which is called sleep hygiene, which can improve the sleep at night, don't encourage it. The only medication sometimes I use is a little bit of melatonin sometimes, five milligrams. That can be okay to use it in certain circumstances. But other than that, I have moved away from these medications. And normal, healthy sleep is without a pill.
Dr. Jonathan Fialkow:
If you’d like to watch the full episode of Resource Live, there’s a link in the notes for this podcast.
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