Transcription:
Addressing Cognitive Decline in the Elderly

Scott Webb: Mental decline begins to happen for all of us in our 30s. And when it comes to our elderly relatives, it's important that we recognize the warning signs of rapid decline and are proactive in making sure that they receive the testing and care that they need.

And joining me today to discuss mental decline in the elderly and what we can do to help is Dr. James Evans. He's a psychiatrist and Medical Director of Behavioral Health Services at Emerson Hospital.

This is the Health Works Here podcast from Emerson Hospital. I'm Scott Webb. So Dr. Evans, thanks so much for your time today. I have a couple of parents in their 70s, so I'm understandably on the lookout for things, cognitive decline, whatever it might be with my folks. And so it's great to have you on, and I'm sure this is great for listeners as well. So as we get rolling here, why do older people tend to decline mentally?

Dr. James Evans: You know, the body ages throughout the life cycle and the entire body is affected by aging, including the brain. The brain is one of the important organs, of course, in the body. And so it goes through its own changes as we age. It's interesting though, lots of studies have been done on normal brain imaging looking at what parts of the brain age and do worse and what parts of the brain actually does better. And what we've found is that there is a peak of brain function that occurs in the third decade in life. And after that, it starts to get a little slower, the brain. So the processing speed starting in the 30s starts to slow down as we age. Along with that, the psychomotor ability, which is the ability of the brain and the body working together to react. So our quick reaction time, our ability to move quickly in response to what our brain is telling us to do, that peaks also in the third decade, and then tends to get slower.

But there's parts of the brain that actually do better as we age. Interestingly, vocabulary's one of those. That seems to be pretty well-preserved into very old age, as well as general knowledge, just what we've picked up through our lifetime and we know that fund of knowledge tends to stick around.

Scott Webb: This is really interesting. I was just thinking I'm 52. So that means I've been declining now for a couple of decades.

Dr. James Evans: Sorry to give you that news.

Scott Webb: Yeah. Which I think I've noticed. But you're right though, my vocabulary is still pretty solid still, still pretty good. So at least I've got that going for me. How do we tell if a loved one is declining mentally?

Dr. James Evans: There are things to look out for, certainly. I would say there's some key things that we should pay attention to when we have an elderly loved one. One is to keep an eye out for their memory. How's their memory doing? Are they remembering things? There is a normal loss of memory as we age, but there's also an abnormal loss of memory as we age, and that's hard to sort out. All older people tend to get forgetful. At what point is that really an issue or a problem? And that might need some further investigation if you notice that going on.

Also, I would say watch out for whether or not grandma or grandpa are forgetting how to do things that they previously didn't have any trouble doing. So activities that they used to do very easily, are they now having more trouble with that? Are they getting lost in the car or they're getting lost on a bicycle? I remember the story of a good friend of mine who was elderly, got on a bicycle for a ride around his neighborhood. And an hour later, he hadn't come back home. His wife got concerned and called him on his cell phone, which fortunately he had with him. And he sounded flustered on the phone and said, "Oh, you know, I'll be right there." She waited another hour. It turns out that he had gotten lost on his bike and was miles from home. And she needed to summon the police. Certainly, that would be of concern.

Other things like falling, if someone begins to have falls or to have unsteady walking, that would be something to kind of keep an eye out for. Another kind of red flag would be a change of personality. If grandma, grandpa just starts to not seem like themselves for some reason, that would be something to keep an eye out for or any other kind of decline in function in which it's clear that they've gone from one level of functioning to another.

Scott Webb: I'm wondering too about decision-making. Is that a red flag we can look out for where, as you say, grandma and grandpa or even our parents, if they just seem to be making decisions we don't think they would've made five or ten years ago, that somehow, you know, something just doesn't seem right. Is that also something we should look out for?

Dr. James Evans: That's absolutely something to look out for. Fortunately, we have good tests that can help us figure out whether this is actually a problem or not. So there's something called a Montreal cognitive assessment that is commonly done even in primary care doctor's offices. And then of course, the gold standard of testing would be something called neuro-psychological testing, which is actually a battery of tests that's done. It takes several hours to do. It's very thorough and it looks at six different cognitive domains of function in the brain and compares answers to the same age group and the same educational level, so that you're getting an apples to apples result. It's very accurate and really would pinpoint if there's an issue at all.

Scott Webb: That's good to know. And I was going to follow up and ask you, you know, what should we do if we're concerned or when should we be concerned and really what would be the remedy for that? So let's just say that we've seen some of these red flags with our relatives, grandma and grandpa, mom, and dad, whomever it is, we've seen these red flags, we're worried about them, what should we do? Should we call their doctor? Take us through this, doctor.

Dr. James Evans: Yeah. So the first thing would be to contact their primary care physician and ask for an appointment, ask to have them brought in. It's very important that we understand whether there's something medically going on first. So very common causes of changes in mental status would be simple things like a urinary tract infection, for example, can throw someone way off. And so that's the first step, is just to rule out anything medically going on. And then, if that's all okay, then you go on to these next steps and looking more closely at what's going on with the brain itself.

Scott Webb: Okay. So what can we do to reduce mental decline? And I'm assuming that early intervention is best. But regardless, whenever a loved one has been, you know, determined to be in decline, what are some things that we can do to reduce or slow down the progression?

Dr. James Evans: Yes. There are a number of things that can be done actually that are fairly well-known. Cognitive training or cognitive retraining is a new discipline that is coming to its fore. It's come out in the past few years and it seems to be having a great promise. It really trains the brain in its cognitive functions and has been seen to restore some people's functioning quite well and that effect seems to last over a period of time. It's very interesting. So that would be something to consider.

But certainly there's a number of other things that can be done to help the brain maintain its function. So there are certain activities that are known to be very helpful cognitively for a person, such as playing bridge, actually playing musical instruments; reading, keeping up with that; using the computer, actively doing puzzles or engaging in reading and discussion groups. So those are all kind of mental activities that are helpful for the brain and keep us on our toes.

Another big category of cognitive help would be just staying active physically. And of course, that includes exercise, especially any exercise that maintains cardiovascular health. But other exercises are helpful as well, such as gardening and even dancing would be really great for the brain.

Then there's the social engagement. Our loved ones should not be isolating. They should be actively engaged, socializing with friends and family, attending cultural events, and travel. These are all things that are well-known to keep the brain stimulated.

Scott Webb: Yeah, all of those things would be good anytime for all of us to stay mentally and physically well, but as you say, especially for those that may be on decline. I wanted to ask about the role of sleep. I know that I don't sleep nearly as much as I used to. I used to be able to sleep, you know, 10, 12 hours as my teenage son can. But I've noticed as I've gotten older that, you know, five, maybe six hours, if I'm lucky. So just generally speaking, doctor, what is the role of sleep in preventing mental decline?

Dr. James Evans: So this is a two-way street and either one affects the other. In cognitive decline, that can inhibit sleep or give poor sleep to somebody and vice versa. So sleep is very important for maintaining cognitive function. The answer to this is that good quality of sleep is really paramount and the sufficient length of the sleep is really important too, because the brain needs a certain number of hours of sleep every night in order to repair itself. There've been studies that have looked at the deposition of abnormal proteins that occurs in Alzheimer's actually, and the effect of sleep on keeping that level of abnormal protein as low as possible.

Apart from dementia, just speaking about normal sleep and normal aging, all of us human beings go through an evolution in what happens to us in and to our brains while we're sleeping. The restorative part of sleep is actually broken down into stages. So stage III and stage IV sleep are the deepest sleep that we get during the course of the night. And those two stages are absolutely essential for feeling refreshed and energized the following morning, but they're also important for cognitive function. And we tend to go into those stages less and less the older we get. So the very old would spend a very brief amount of time in stage III and four IV sleep at night. And that is an issue. So it's really important that our sleep hygiene is the best we can make it to encourage the brain to spend as much time as possible in that deep sleep stage.

Scott Webb: I see what you mean. You know, there's just no way to get away from the pandemic and COVID-19 over the past year plus. So I'm curious, has the pandemic created additional mental decline among the elderly due to loneliness, isolation, change in routine and just a change in their daily lives?

Dr. James Evans: We should put this into the context of stress in general. So, the pandemic has certainly been a huge stress for everybody this year. But in terms of cognitive health, any stress is to be avoided if possible. The more we can do to make our lives serene is what we should be aiming towards. And in that regard, meditation, for example, has been found to be really important to decrease stress. And there've been studies on people's brains who practice meditation in which there are changes that occur to the neurons, which are the brain cells, that look like they are making new connections. And this is really important for the overall function of the brain.

Scott Webb: That's pretty amazing. And I have heard a lot of stories during the pandemic of folks taking up, you know, meditation and yoga, things like that. Lots of free resources out there, apps on their phones and so on. So good to know that there's a lot of benefits to the things that you're mentioning here.

Dr. James Evans: In addition, I also want to mention diet. Even though our brain is only 2% of our body weight, it uses 20% of our calorie intake. It's amazing how much nutrition our brain needs on a daily basis. And so what we are feeding ourselves every day is really important for brain health.

There are a number of recommendations now in terms of what is good food, what is good nutrition, the so-called Mediterranean diet, which is of course, just not overly processed foods, and the role of nutrition in modulating inflammation in the brain and adding to our antioxidant reserve.

One of the findings in dementia, for example, is that in some people, there seems to be an ongoing brain inflammation and what we eat seems to be important in helping tamp that down. In particular, there's something called phenols, which are compounds that are found in fruits and vegetables, tea, wine, and some herbs like turmeric, which can mitigate the inflammation and oxidative damage, that has been found in research.

Scott Webb: Are there any promising advances in treating aging, mental decline, Alzheimer's and just the related diseases?

Dr. James Evans: Well, I want you to ask me the same question in about five years, because I think we're going to be in a very different spot then.

Scott Webb: I will. It's a date.

Dr. James Evans: Okay, good. Right now, the treatments that we have are not the greatest. I'll just be very honest. We have a couple of classes of medications out there that are to prevent a decline. They just don't seem to work very well. There's been a bunch of multi-center studies looking at the effects of these medications. And as a geriatric psychiatrist, I've come to conclusion that the side effects outweigh the benefits of these medicines.

There's also a new medicine that's just come out. And unfortunately, that looks to be in the same kind of category, that there's some very potentially serious side effects that can occur. And I don't think I'm going to be prescribing that medication either for my patients. But I think the research is moving ahead rapidly. And I think it's not too far away that we're going to have very effective treatments for mental decline and for Alzheimer's in particular.

Scott Webb: That's great to hear. I was going to ask you as we wrap up here, what are you most hopeful about? So besides our appointment in five years to get back together and talk about how far things have come for treating mental decline, what are you most hopeful about, doctor, at least at the moment right now for grandma and grandpa, mom and dad, whomever might be facing this mental decline?

Dr. James Evans: I think what we have now, we're becoming so much more aware of the issues that are involved in this and how to help people live a better quality of life in a way that we did not know how to do this a generation ago. I think this is all good news and I trust that as each of us goes through life, that we will have continuing good quality of life to the very end.

Scott Webb: That does make me hopeful as well. And that sounds good. I look forward to that hopefully, and look forward to speaking with you again in the future, as the treatment for mental decline just advances so rapidly. So doctor, thank you so much for your time today and you stay well.

Dr. James Evans: Okay, thank you very much.

Scott Webb: Visit emersonhospital.org for information and emersonhospital.org/podcast to hear additional podcasts about mental health topics. And thanks for listening to Emerson's Health Works Here podcast. I'm Scott Webb. And make sure to catch the next episode by subscribing to the Health Works Here podcast on Apple, Google, Spotify, or wherever podcasts could be heard.