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0:05
- First today we have Dr. Greg Cooper. He is chief of the Adult Neurology and director of the Norton Neuroscience Institute's Memory Center. Dr. Cooper focuses on the care and treatment of individuals with Alzheimer's disease and related disorders, and has been active in research serving as principal investigator on a number of clinical trials. He also has a strong interest in education and caregiver support.
0:32
Dr. Cooper earned his medical and doctorate of philosophy degrees from the University of Kentucky before completing his residency in neurology and fellowship in behavioral neurology and cognitive neuroscience at the University of Iowa. He briefly directed the University of Iowa Dementia Clinic before joining the Sanders Brown Center on Aging at the University of Kentucky. Dr. Cooper later formed and directed the Baptist Health Memory Care Program
0:59
until joining Norton Neuroscience Institute in 2021. Please help me welcome Dr. Greg Cooper. (audience applauds)
1:12
- Well, thank you all, and thank you all for being here. This is my first in-person expo and I'm pretty excited to see all this come together. So my topic today and I'll be reasonably brief, I'm talking about aging in the brain, so the aging brain and then talking about memory, dementia. And the outline is this, we'll talk about memory, we'll talk about aging, then we'll talk about impaired aging, so normal versus impaired aging. Talk about some warning signs
1:45
and then I'll finish up with a few strategies for brain health. And for those of you interested, I really encourage you to listen to the talk at noon, which will have quite a focus on prevention.
1:58
So if we think about aging in the brain, variation is the rule. And the older we get, the wider that variability of normal can be. And given that people have started dividing aging up in three different categories. So they're successful aging, meaning when I'm 80 years old, my brain is just the same as it was when I was 20 years old. And then there's usual or normal aging, meaning there are some changes that typically go along with age. Now, I'll point out these are usually fairly mild,
2:31
but there are some changes that most of us will experience. And then there's the impaired or diseased aging, which we'll talk about. Now, it used to be thought that cognitive decline or really even a dementia was just a normal part of aging, just senility. And fortunately we've realized over time that's not necessarily the case. There may be some changes, but it's not inevitable that we're gonna experience significant change. And people sometimes will refer to those different aspects
3:03
of cognition when they talk about some of the normal changes as fluid intelligence and crystallized intelligence. And by fluid intelligence, what we mean are things like problem solving, mental flexibility. To some degree, maybe our ability to learn new facts or new items or new skills. So those may decline a little bit. It may take me longer to solve a problem, it may be a little bit harder for me to learn things. It doesn't mean I can't, I can still get to the successful solution,
3:33
but I may not be quite as adept as I was 30 years ago, for example. And then there's crystallized intelligence and that's typically preserved. So these are things like information that we've already learned, vocabulary, skills that we've already learned, and in fact, overall judgment and wisdom can even improve with age.
3:54
So now let's think about that spectrum of cognition across aging. And if we divide it up in those three categories, again, successful, usual, and impaired. We have successful aging, meaning when I'm 80, 90 years old, my cognition is just as good as it was at any point in my life. And there some of us that are lucky enough to experience that. And then there's usual aging where we have some minor changes like what I just talked about. Maybe my flexibility is a little lower.
4:23
Maybe my problem solving is not quite as good. So that would be usual aging. And then we have cognitively impaired aging. And these are conditions like mild cognitive impairment and dementia. And I'll talk a little bit more about that as we go along. So if we look at it sort of as a graph, so along the bottom axis we have that spectrum of cognition. And along the vertical axis is cognitive function. So at the very far end, you have successful aging. This is what we all want.
4:53
As I get older, there's no change in my cognition at all. And then you have age associated memory impairment, and that's another way perhaps of thinking about usual aging. And you can see a slight decline. But again, slight, this is a small change, but that's what many of us will experience as we get older. But if that gets a little bit worse, if I start having more prominent changes in memory or thinking or cognition, that pulls me into mild cognitive impairment category.
5:23
Again, I'll talk about that in a minute. And if it's more severe than that, at that far end, that's where we have dementia. So let's talk about those things. Mild cognitive impairment, the simplest way to think about it is this, I have an impairment in one or more areas of cognition. Very often it's going to be memory. So I may be more forgetful, I may not recall items as well. I may repeat myself more often. And that is more than I could explain just by normal aging,
5:54
but it is not to the degree that it's preventing me from doing my day-to-day activities. So that, broadly speaking, is the definition for mild cognitive impairment. Now, if I have impairments in multiple areas of cognition, so it may be memory, it may be language, more trouble coming up with words, it may be my visual spatial function, I may have more trouble navigating from point A to point B, any number of things. But the point is I start having problems in multiple areas
6:25
and now it's impairing my daily activities. So in other words, I have to have family members take over management of my medications or my finances or any number of things. So when I'm at that severity, that's when we worry about a dementia.
6:42
Now, talking about mild cognitive impairment, again, it's a very common condition and probably the best estimates of any of us over the age of 65, 10%% to 20% of us will have mild cognitive impairment. So it's very common. There is a risk that that will convert to dementia. It puts us at a higher risk of dementia, and that risk is probably around 10% to 12% per year. So if I have mild cognitive impairment today, next year, I have a 10% to 12% chance
7:13
that that will have progressed into a dementia. But it's important to point out that can also revert back to normal. And the numbers are all over the board on this, but the range I was able to find is anywhere from 14 to 55,
7:27
55% of people with mild cognitive impairment will revert back to normal cognition. And so for that reason, it's sometimes referred to as an unstable diagnosis. If I have mild cognitive impairment today, I may still have that next year, or I may have progressed to a dementia or I may have reverted in this case back to the left, back to normal aging.
7:53
So now let's talk about dementia. And I already defined this, but again, it's a condition where I have impairments in multiple spheres of cognition sufficient to impair my activities of daily living, my daily functioning. There are many causes of dementia. Way back when when I trained, it was always said there were over 120 causes of dementia. And that's true. There are four main causes, and really even if I just listed the top three, that would get us almost all cases of dementia.
8:28
So Alzheimer's disease is the most common cause of dementia, and it's marked by impairments in memory, particularly short term memory. And another way of looking at it is it's a disorder affecting our ability to learn. So things that I learned 20 years ago, I hold onto those, but I can't recall what I did yesterday because I can't form that memory accurately. So I have problems with my short-term memory. Now, as that advances, I will start having problems with language, problems with orientation
9:02
and may eventually start having problems with long-term memory. But early on it is really a problem with learning and short-term memory. And then there's vascular dementia, and as would be implied in the title, it's associated with vascular disease. That may be a stroke or it may be in a sense more insidious than that just continued plaque buildup in the arteries leading to my brain that start to cut off the flow of blood, of oxygen, of nutrients to the brain.
9:31
And that can cause a slowly progressive dementia. In this case, yes, there may be memory, but more than that, you might see problems with planning, with organization. My cognition is slowed. I get the answer, but the wheels are turning more slowly. I may be physically slower as well. I may take me longer to walk from side to side in the room. Everything just seems to slow down. And then there's dementia with Lewy bodies. And this is very much related to Parkinson's disease. Some will even say,
10:01
this is on a spectrum with Parkinson's disease. And in that case I may have some physical changes like stiffness or slowness. I often have a lot of fluctuations, a lot of ups and downs. And I may have prominent hallucinations, particularly visual, seeing things, seeing people, seeing animals. And then frontotemporal dimension, I'm not really gonna talk much about that. It's its own separate category. And in it, I may have problems with language, I may have problems with personality,
10:28
I may have really quite drastic changes in my personality. So let me pivot a little bit and talk about warning signs and this one, many of these I stole from the Alzheimer's Association or other organizations. The first one I put up, the number one warning sign to me is a clear change in cognition, especially when it's noted by others. So, well, if I see somebody Monday who says, and they come by themselves and they really are concerned that they're developing Alzheimer's disease,
11:03
the odds are very high that they are not. If somebody comes into my office and says, "I'm doing fine, but my family's driving me crazy 'cause they think I have a problem." That's when I'm really worried about it. Now, that's not a hard and fast rule, but in general, if we're noticing problems, it's probably not something to worry about it. If we truly have a memory problem, as silly as this may sound, we don't remember what we don't remember. So it's gonna be our friends and families
11:34
that really note it. So any clear change, especially when noted by others, that's probably number one on my list. But some of the common warning signs to think about. So getting lost in familiar places. So that doesn't mean me getting lost in Downtown Louisville 'cause I don't know my way around, but if I get lost in my neighborhood where I should know my way around, that's a problem. Forgetting recent events, repeating myself over and over again, odd, strange, inappropriate behavior,
12:02
changes in personality, decline in my ability to plan, organize, change in my diet or eating habits. Now, I only want to eat sweets. Changes in my hygiene, I'm not taking care of myself. More apathy, I just don't seem interested, I don't care. And changes in language ability that may be coming up with words or may be understanding others. All of those are potential warning signs, potential warning signs. Now, thinking about warning signs versus what's just a normal lapse.
12:35
So if I'm able to recall detailed accounts of when I didn't remember something, that's probably normal. We all have that. On the other hand, if I can't recall times where I didn't remember something, but my family can, then I'm more worried. If I'm more concerned, then the odds are, it doesn't mean it shouldn't be checked out, but the odds are I'm okay. If my family is more concerned, then that's more worrisome. Occasionally having trouble coming up with a word,
13:04
that will happen before I'm done here, I'll have some trouble coming up with a word. We all do that, and that's normal. But if that's frequent, if there are frequent pauses, if I'm having to use a lot of substitute words, that's more worrisome. Having to pause to remember how to get somewhere versus getting lost in a familiar area.
13:25
Able to operate common appliances or an unwillingness to learn. So if I just refuse to learn how to use the remote control versus I'm really trying and I just can't figure it out. And then finally, maintaining prior levels of interpersonal skills versus just inter inappropriate behavior or loss of interest.
13:45
Well, it's still worth pointing out though that no single sign indicates the presence or absence of a dementia. So all of these things may worry us to a greater or lesser degree, but it shouldn't be taken to mean that any one of these means I do or do not have a dementia. So let me pivot just a little bit and talk about strategies for brain health. And again, if you listen to Dr. (indistinct) talk, that will be far better. But this will kind of set the table for that.
14:15
I think it's useful to think about some of the prevailing hypotheses about brain health and in particular in terms of dementia prevention. So the first one is the vascular hypothesis. And what it really says is this, what's good for the heart is good for the brain. There is a close connection between our vascular system and our brain. And if we take care of our vascular system, we'll take care of our brain. So that's probably number one. A stress hypothesis.
14:43
Stress can cause a release of stress hormones, which can be toxic to the brain. All of us have stress, we can't avoid that. But if we have more robust social networks, that seems to mitigate the effect of that stress. So that may be protective for us. And then the cognitive reserve hypothesis, and this is simply saying that more mental and physical activity builds up our cognitive reserve and the more reserve we have, the better protected we are against developing a cognitive decline
15:16
or dementia down the road.
15:19
Now, the Lancet Commission has issued two reports now. This is a International Commission of experts. First report I think was in 2016 and more recently in 2020. And what they said really has had an impact on me. They said that 40%, 40% of dementia worldwide is preventable. That's a huge number, 40%. They've identified 12 risk factors that they believe can account for that. And this number is actually growing over time. And I know it's kind of small print, but let me just read through it.
15:57
So minimizing diabetes, treating high blood pressure, preventing head injury, stop smoking, reduce air pollution, reduce midlife obesity. Those six risk factors operate by reducing actual damage within the brain. So for instance, in the case of Alzheimer's disease, that's buildup of proteins called amyloid or tau.
16:21
Three others, maintained frequent exercise, reduce occurrence of depression, avoid excessive alcohol. That helps us in two ways, it reduces the pathologic changes in the brain, it also increases our cognitive reserve, which you recall we talked about in the last slide. And then the last one is treating hearing impairment, maintaining frequent social contact and attaining a high level of education. And that works by increasing and maintaining our cognitive reserve.
16:50
And then together, all of these things prevent dementia. So let's think about that in a little bit more detail. So if we think about risk factors, particularly risk factors we can do something about. One group has divided that up by period of life. So in early life before the age of 45, education may be the most important risk factor. Now I'll say as an aside, I don't think that needs to be limited to early life. We can continue to learn and stimulate our brains
17:19
throughout our lives and that can still be helpful. Midlife, excessive alcohol. Now, there are some people that believe excessive alcohol means anything more than zero. And there are others, and these are real scientists who would say excessive alcohol means more than about a drink a day.
17:39
And you can even find people that say one drink a day might be a good thing. So, there's debate there. There is no debate that once we start getting more than one or two drinks a day, that does become toxic to the brain. Everyone agrees on that. So excessive alcohol, hypertension, HTN stands for hypertension or high blood pressure, obesity, hearing loss, and TBI is traumatic brain injury. So all of those things are risk factors in midlife. And then in late life, smoking, social isolation,
18:10
physical inactivity, and air pollution. Now, some other risk factors to think about, anxiety, depression, there's some debate here, is depression a risk factor that leads to dementia or is it an early symptom of dementia? So it's a little bit hard to untangle that, but I think it's something we ought to pay attention to. Heart disease. So besides high blood pressure, what about atrial fibrillation and heart failure? And then sensory impairment.
18:37
And that can be hearing loss, that can be vision loss and doing anything we can to help treat or mitigate that. And then other factors, cancer, polypharmacy. This just means taking a lot of medications. We always want to try to minimize the medications to the point that's reasonable. Treating diabetes, treating lung or respiratory disease, avoiding brain injury. So what are some general recommendations? First of all, good general healthcare.
19:08
Treat diabetes, treat high blood pressure if it's there, don't smoke, watch our weight, get into a normal body weight, avoid head injuries and limit alcohol.
19:20
And then some other lifestyle strategies. So regular mental exercise and there is research that might indicate the details don't matter, but whether it be reading, learning a language, learning an instrument, taking a class, anything that stimulates us mentally, regular physical activity or exercise, as simple as walking five days a week is helpful. And then regular social contact, building that social network. What wasn't listed with the Lancet Commission,
19:50
but I think might be in their next report, is maintaining adequate sleep. And a good target is seven or more hours a night. And then diet, and there too the Mediterranean diet and the mind diet, which stands for Mediterranean-intervention for neurodegenerative delay. And that one's worth pausing on a little bit. If I follow the mind diet religiously, the evidence would suggest I reduce my risk of dementia by half. If I follow the mind diet pretty good, not religiously,
20:22
but pretty good, I probably reduce my risk by about a third. So, what is that? It lists 10 foods that we need to eat more of and five that we need to eat less of. And I won't go over all the details, but basically getting leafy green vegetables and other vegetables about once a day, serving a day, nuts, berries beans whole grains fish poultry and substituting olive oil for other fats or oils. And then the ones that we should avoid, which I'd like to go over very quickly, red meat,
20:57
and they're pretty reasonable. Less than four servings a week, avoid butter and margarine, limit cheese. The last two are a bit painful, limiting pastries and sweets to five servings a week. And fried or fast food. I think I can do them all but the sweets, that one's a little hard.
21:15
And then this is just a picture that I stole. But again, looking at all of that from the Wisconsin Alzheimer's Disease Research Center, just going over the mind diet.
21:38
(soft music)
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