| True or False | |
| Memory loss is normal and to be expected as we get older. | ____ |
| The brain keeps producing new brain cells until we die. | ____ |
| Normal aging is linked to a loss of intelligence. | ____ |
| You need a CT scan if you have unexplained memory loss. | ____ |
| (Answers at end of chapter) | |
Many older—and not so old—adults share a common fear: loss of memory. I’m sure you’ve been asking yourself some of the typical questions: Is it all right to misplace my keys now and then? Does aging really make it harder to learn and easier to forget, or am I just suffering from information overload? When should I laugh off forgetfulness—and when should I be worried for myself or a loved one? Do those brain-training exercise programs really work?
To answer these questions as well as some others, it is helpful to understand how our brains change as we approach middle age and beyond.
The brain certainly changes as we age. The brain is an organ, so just like every other organ in your body, it’s going to change as you get older. So what are the normal changes?
Well, first of all, the brain does shrink in size; more specifically, the weight of the brain and its volume decrease. Starting around age 25, we gradually lose weight and volume in our brains. The decline is estimated to be about 2 percent per decade. So by the time we are 75, we have lost about 10 percent of our brain size.
That may seem like a lot, but 10 percent is actually not that much of a loss. Not all portions of the brain shrink, or shrink to the same degree; some shrink more than others. For instance, since we are talking about memory, the two areas of the brain that are responsible for memory—the frontal lobe and the hippocampus—typically shrink more than others. That’s part of the reason why we develop memory problems.
It is also true that we lose brain cells, called neurons, as we age. How many? Up to 50,000 a day. Don’t worry, though, because we have billions of neurons. And that neuron loss occurs throughout our adult lives, not just as we get older.
Some neurons also shrink in size. This matters because their smaller size makes them less effective. They transmit electrical and chemical signals more slowly than they did when we were younger. In addition, as we get older, our bodies make less of the chemicals that our brain cells need to work. That can cause a general slowing of our mental functions.
The grooves on the surface of the brain also widen, while some surface elements become smaller. Just as the blood vessels in the heart develop plaque, the brain also develops plaques and tangles, which in the brain are pieces of dead neurons. These plaques can take up space in living tissue that is responsible for important mental functions, and interfere with your brain’s ability to perform these functions.
Did you have your computer installed by an expert, connecting Internet, video, television, and telephone wires? Have you ever looked behind the computer console? There are so many wires and connections—I have no idea how they all go together. When trying to understand how the brain works, I like to compare it to a sophisticated computer.
The brain is an intricate system of connections. Neurons communicate with one another via chemicals called neurotransmitters. As we age, some connections get lost, and other connections become weaker. This does result in some problems with our thought processes.
The good news is that we can develop new connections even as we get older. The brain is amazingly adaptive and can renew and repair itself. This ability occurs throughout life. Just because brain cells die does not mean that you will automatically experience a significant decline in your mental function. Rather, throughout life, including older age, our brains have both gains and losses, typically keeping everything fairly balanced.
As we get older, we do not lose intelligence. That is one of the biggest myths—that as we get older, we lose our “smarts.” Our cognitive ability typically stays the same in adulthood up through our early sixties. At that point, there is a small decline, but the effects of cognitive changes typically are not noticeable until we reach our seventies and beyond.
Many people continue to gain expertise and skills throughout life. I’ve known many retirees who got bitten by the travel bug and learned a new language to give them a richer experience. It may take more time to master something like a new language, but older adults still have the ability to do so. Just like computers have a processing speed, so do our brains. With age, our information processing time slows down. This reduced processing time may make it more challenging to multitask. When we’re younger, we’re able to talk on the phone, type on the computer, and clean our desk—all at the same time! As we get older, we cannot process all of these tasks as quickly or simultaneously.
It is important to point out, though, that new learning can occur at any age—yes, you can teach an old dog new tricks! As a lover of words, I’m happy to tell you that our vocabularies continue to increase throughout our lives, especially if you continue to challenge yourself to read and learn new words.
We basically have two types of memory: short-term and long-term. Short-term refers to recent events, such as what you had for dinner last night, what the doctor told you at your recent appointment, or what you read in the newspaper last week. Long-term memory refers to events in the distant past, which is typically defined as remembering details and events that occurred years ago.
Forgetfulness does tend to increase with age. Let me phrase it another way: Memory lapses are a normal part of aging. Everyone forgets things, and occasional short-term memory loss is normal as we get older. That’s why you occasionally forget where you put your keys, whether you locked the door, or perhaps what’s on television on a Thursday night. It is also normal to occasionally forget an appointment or to forget the names of acquaintances. We all have those “tip of the tongue” moments. Such memory loss is not usually a warning of serious impairment. If you are concerned and aware that you are forgetful at times, that can be a good thing, since folks with dementia often are not aware that they are forgetting.
If you’ve ever watched a soap opera, it seems like some character is always suffering from “temporary amnesia” and miraculously regains his or her memory. The truth is, that doesn’t happen much in real life, but some causes of memory loss are reversible.
The most common cause of memory loss is medications. Numerous drugs have side effects or interactions with other drugs that can affect memory. Examples include some blood pressure medications, sedatives, and narcotics.
Minor head trauma or injury, such as a concussion, can cause temporary memory loss. Think of the sacked quarterback who is dazed and can’t remember for a few moments who he is or where he is. We now know that head injuries, especially on the athletic field, can be quite serious, and the brain needs time to heal. Fortunately, if the injury is minor, the brain does heal and memory returns.
Mental health disorders, especially depression, anxiety, and post-traumatic stress disorder, can cause temporary memory loss and confusion. But if you treat the underlying mental health issue, memory usually returns.
Substance abuse—alcohol and drug use—often can cause memory problems. With alcohol abuse, it’s often due to the associated thiamin and B12 deficiency. These nutrients are involved in keeping the brain functioning normally, both forming and recalling memories. Marijuana, cocaine, and other drugs block our brain chemicals from creating memories.
Environmental toxins can also cause memory problems; these typically include lead in drinking water or paint, carbon monoxide in home heaters, and chemicals in various pesticides and home cleaning materials. Have you ever tried to breathe in the bathroom after a thorough cleaning with various chemicals? It definitely can make you woozy!
Infection is a major cause of older persons becoming confused and disoriented. Again, this usually happens suddenly. Once the infection is treated, the person returns to normal.
Some overlooked causes of memory loss include dehydration, which can be quite common in the elderly, as well as thyroid problems. Sometimes people are either over- or undermedicated on thyroid replacement, and this causes some memory problems and confusion. Poorly controlled diabetes can also cause problems with your thoughts and memory. (Try appearing normal when your blood sugar is dangerously low or high—I bet you can’t!) Hearing loss is another overlooked area that is mistaken for brain problems. Too often, people cannot hear what was said, they are too embarrassed to ask someone to repeat it, and then they cannot remember it because they never heard it in the first place!
Finally, the hospital setting itself can actually cause confusion and memory loss, especially as we get older. It is a strange setting that disrupts sleep patterns, and new medications are typically started, often narcotics. As anyone who has ever had a baby knows, lack of sleep can cause mental confusion and temporary memory loss and forgetfulness—and hospitals can be tough places to get a good night’s sleep.
There is a big difference between normal absentmindedness and the types of memory loss associated with dementia such as Alzheimer’s. Some forgetfulness and slowing of mental responses are a normal part of aging. After all, aging affects memory by changing the way the brain stores information and thereby makes it harder to recall stored memories. However, significant memory loss is not a normal part of aging.
So what’s considered “significant” memory loss? When evaluating the seriousness of memory loss, you want to determine whether the forgetfulness is gradual (over many months to years) or sudden (several days, weeks, or a couple of months). If memory loss is sudden, it’s typically not related to Alzheimer’s. Normal memory loss is not sudden, and it doesn’t significantly worsen over time; dementia also starts slowly but gets much worse over several months to several years. Sudden memory loss is usually related to one of the reversible causes mentioned earlier.
Some “red flags” that should raise concern for you or a loved one include:
• Trouble remembering how to do things you’ve done many times before, such as driving to your favorite restaurant, playing golf, or loading songs onto your iPod
• Forgetting things much more often than you used to, such that you are forgetting something every day
• Trouble learning new things such as a new computer skill
• Difficulty following directions effectively
• Trouble handling money
• Repeating phrases or stories in the same conversation
• Appearing disheveled/unkempt, with changes in grooming
| Memory: What’s Normal and Not Normal As We Age | |
| Normal | Not Normal |
| Occasional memory loss of recent events | Loss of long-term memories |
| Difficulty multitasking efficiently | Gradual, progressive memory loss |
| Needing more time to get a job or task done | Unable to complete simple tasks or name family members |
| “Tip of the tongue” moments | Sudden memory loss |
Exhibiting any of these symptoms should prompt medical attention.
Alzheimer’s is a disease of the brain that affects our memory as well as our thinking and behavior. It is the most common form of dementia. Unfortunately, it is not reversible and gets progressively worse over time.
Alzheimer’s is not a normal part of aging. In fact, no type of dementia should be considered normal. Contrary to what you may have been told, we do not become senile just because we get older.
Symptoms of Alzheimer’s typically first include memory loss, and then progress to changes in thinking and then finally behavior. Typically, early Alzheimer’s disease causes a person to be unable to complete tasks that are familiar. An example would be when the person gets lost while driving on familiar streets and routes. Misplacing your car keys is normal, but if you misplace keys in an inappropriate place—such as the freezer—that should raise an alarm. Because Alzheimer’s affects short-term memory at first, those developing the disease often ask the same questions over and over, since they cannot retain the answer. They are less able to follow directions; you often see this when they cannot follow a recipe, even if in the past they were an excellent cook.
As Alzheimer’s progresses, patients start to mix up words because their memory problems impact their thinking ability. They use the wrong word or have difficulty remembering common words (e.g., a pen or a clock). They often undergo personality changes, resulting in unusual behaviors. As the disease worsens, they become unable to take care of themselves, unable to perform what we call activities of daily living (e.g., eating, bathing, walking, climbing stairs, grooming). Finally, long-term memory is impacted, but that’s usually the last cognition to be affected.
Although most people are quite fearful of Alzheimer’s, only 6 percent of those in their sixties are affected by the disease. It rarely affects anyone in their forties or fifties, and it is highly unlikely you or a loved one has Alzheimer’s if you’re not at least 60. The incidence does increase each decade after 60, and with our aging population, more people will develop Alzheimer’s. Approximately 30 percent of people will have some degree of Alzheimer’s by the time they are over 85.
If you are concerned about memory loss—whether for yourself or a loved one—you should see your doctor, and possibly a neurologist. You will undergo neuropsychological testing and will likely need a CT scan, PET scan, or MRI.
One of the simplest tests that you can administer to a loved one, or have someone administer to you, is the mini-mental status exam. Physicians will give you this test if they suspect dementia, but there’s no reason why you can’t also administer this test to someone else (if you’re concerned about your own memory loss, ask someone to administer it to you).
The MMSE,1 also referred to as the Folstein test, is a brief 30-point questionnaire that doctors often use to screen for dementia. It can also help a doctor determine the severity of any cognitive impairment. The questionnaire takes about 10 to 15 minutes to complete and basically focuses on the following areas: orientation, registration, attention and calculation, recall, and language.
What is the year? Season? Date? Day? Month? _____
One point for each correct answer. Maximum score of 5.
Where are we?
State? County? Town? Hospital/Building? Floor/Room? _____
One point for each correct answer. Maximum score of 5.
Name three unrelated objects (e.g., fast car, blue ball, button), taking 1 second for each. Then ask the patient to repeat all three objects after you have said them.
This first attempt determines the patient’s score (out of 3), but keep saying them until the patient can repeat all three.
_____
Ask the patient to begin with 100 and count backward by 7. We call these “serial sevens.” Stop after five subtractions (93, 86, 79, 72, 65).
Score the total number of correct answers. _____
An alternative is to spell the word “world” backward.
The score is the number of letters in correct order, e.g., dlrow = 5; dlorw = 2.
Ask the patient if he/she can recall the three words you previously asked him/her to remember.
Score 1 for each correct answer. _____
Naming: Show the patient a wristwatch and ask him or her what it is. Repeat for pencil.
Score 1 for each correct answer. _____
Repetition: Ask the patient to repeat a sentence after you. Allow only one trial.
Score 1 if the repetition is completely correct and zero if it is not. _____
3-Stage Command: State a command first and then give the patient a piece of plain blank paper.
Score 1 point for each part correctly executed. _____
Reading: On a blank piece of paper print the sentence “Close your eyes” in letters large enough for the patient to see clearly. Ask him or her to read it and do what it says.
Score 1 point only if he actually closes his or her eyes. _____
Writing: Give the patient a blank piece of paper and ask him or her to write a sentence for you.
Do not dictate a sentence; it is to be written spontaneously.
It must contain a subject and verb and be sensible. _____
Copying: On a clean piece of paper, draw intersecting pentagons, with each side about 1 inch, and ask him or her to copy it exactly as it is.
All 10 angles must be present and two must intersect to score 1 point. _____
| 25-30 Normal | 21-24 Mild Dementia |
| 10-20 Moderate Dementia | < 9 Severe Dementia |
Remember, this is a screening tool. If the results are not normal, more testing might be required.
I wish I had some more information to share with you here. There is some good evidence that a healthy diet as well as exercise—both physical and mental—can help reduce or delay memory loss and possibly Alzheimer’s.
Physical exercise can be as simple as walking. A recent study shows that walking about a mile a day—or 6 miles a week—appears to maintain brain volume and preserve memory in old age.
1 Write things down. Keep lists and make journal entries. Maintain a detailed calendar. Use self-adhesive notes and put them on a door or mirror. If you need to remember something important, it doesn’t hurt to write it down, and then put that piece of paper where you’ll see it. Just consider it to be a gentle reminder.
2 Establish routines and follow them. I always put my office keys in my briefcase right after I open the door. I don’t put them on the desk or in my pocket. That way, I always know where they are.
3 Make associations and connections. This means a couple of things. If you can link an event or a memory to another event or memory, you’ll be more likely to remember it, since you’ve established connections in your brain. For example, you might associate the first name of a colleague at your company to the name of a best friend from high school. Or you might connect the route to your favorite restaurant with the route to your child’s school. The more connections you make to events or facts, the more you’ll increase the chances that you’ll remember them later in life.
Similarly, I also recommend being socially connected. Remember, depression can cause memory problems; if you become more socially connected, you are less likely to become depressed.
4 Stay active both physically and mentally.
As I look back on it, I think the first time I briefly thought about Alzheimer’s in my father was probably when he got lost while driving me to the airport one day. He must have driven that route at least a hundred times, so I was a bit surprised when he started to get confused about which road to turn onto. I attributed it to him being distracted. But the second time it happened, a few months later, caused me to pause. After all, my father was not only an excellent driver but he was always precise; he was a “numbers guy”—an accountant by training who always seemed to be doing calculations. So a driving error was quite imprecise. It didn’t happen every time he drove me, but it happened enough times that I started to get a little concerned. About a year after those incidents, he started to get lost in the neighborhood. At that time, we just attributed it to him getting older, not thinking it was that serious.
As the months progressed, I noticed other changes, mostly small at first. I will admit it: My father seemed to be getting a bit moody as he got older. But we all figured that some mood changes were to be expected with retirement. Like a lot of men of his generation, my father worked hard to support his family. He even worked two jobs for a time to help pay tuition costs for college and medical school. So my father never really developed too many hobbies (golf wasn’t the “in” thing to do back then, but he did like to bowl sometimes!), and we all attributed some moodiness to boredom. He did, however, light up when spending time with his grandchildren.
I started to get more concerned when my father started to repeat certain words and phrases that did not make sense. This was highly unusual since my father was a very smart man. He rarely made grammatical errors. Nonetheless, it’s hard for a family to think about the diagnosis of Alzheimer’s, knowing all the emotions that go along with such a diagnosis.
My mother eventually took him to a neurologist, who did neuropsychological testing, and indeed he was given a diagnosis of Alzheimer’s. At first, my father was very upset by his forgetfulness, but as the disease progressed, it didn’t seem to bother him. He seemed to be unaware of it. Over the next couple of years, my father—always accompanied by my mother and often my sister—was in and out of the doctor’s office, trying different medications to treat memory loss (none of which seemed to help) as well as symptoms of agitation and sleeplessness (some success). Ultimately, his condition rapidly deteriorated over 3 years, which is a bit unusual for Alzheimer’s. Often, it’s a long process, known as the long good-bye. Our family decided to keep him at home and arranged home hospice. In the end, my father was able to die peacefully at home, surrounded by his family.
I’m not sure if recognizing his symptoms earlier and being given the label of Alzheimer’s would have made much difference in my father’s care, given where we are, or more accurately where we are not, with treatment options. I do believe, however, that early diagnosis can encourage some families to spend more time with loved ones now before it gets too late.
Reading books, newspapers, and magazines, doing crossword puzzles and games like Sudoku, watching educational television shows, and participating in hobbies may all help keep your brain as sharp as possible. These strategies have not been proven to prevent or delay the onset of dementia, but they are likely to help keep older minds sharp.
You probably have seen various supplements and vitamins being promoted to improve memory and prevent Alzheimer’s. We just don’t have any good information to suggest that they do; some supplements and vitamins have other beneficial health effects, but don’t take or buy one simply to improve memory.
Finally, manage any medical conditions such as high blood pressure, heart disease, and diabetes, which can increase your risk of stroke and cause memory loss and brain problems.
There are currently some genetic tests that can tell you if you’re at risk genetically to develop Alzheimer’s. But it’s important to remember that genetics is just one component of your risk of developing Alzheimer’s. Even if you are at risk, it does not mean you will develop it. In addition, we currently do not have any truly effective therapies to delay or cure Alzheimer’s. So when patients ask me if they should have a genetic test, I ask them, “What would you do with the information?” That answer is intensely personal: Every person has to decide for him or herself how to live and plan for the rest of their life.
I would be remiss if I did not mention the role of caregivers in a chapter that discusses Alzheimer’s. Many of you reading this book are or have been a caregiver for an elderly parent at some point. Nearly one out of every four households provides care to a relative age 50 or older. What is particularly impressive is that the average age of a primary caregiver is 60 years old—and as you’d suspect, nearly 75 percent of them are women. (I always tell couples planning to have a baby that one of the major factors in not being admitted to a nursing home is having a daughter.)
I really consider these caregivers to be heroes. It is an enormously challenging job. Caregivers often experience a sense of burden, and some researchers estimate that nearly 50 percent are depressed. Many are sleep deprived and exhausted. I’ve seen the physical and emotional toll it can take on numerous family members and friends. Given their age, the lack of sleep often exacerbates their own health problems. They really are the “hidden patient,” and we need to do a better job of focusing on their care as well.
Answers to true/false statements: True, True, False, True