Melanie (Host): Welcome to Meaningful Medicine, a Novant Health podcast bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. I'm Melanie Cole. And today, we're learning about memory, cognition, and dementia.

Is it forgetful or something more? Joining me is Dr. Robert Wiggins. He's a neurologist with Novant Health. Dr. Wiggins, welcome to the show. Thank you so much for joining us today. I'd like you to start by telling us a little bit about memory loss. Is this something that is a natural part of aging? Is it inevitable?

I mean, because I'm 62, and I am noticing myself forgetting words, forgetting things all the time. What's considered normal forgetfulness? And, you know, when does it become something more concerning?

Robert Wiggins, MD: Of course, we all feel that way, right? I mean, even I think that I'm forgetting names more often, forgetting to do this or forget to do that. And there is this process we call normal cognitive aging, which is effectively just the brain is taking a little bit longer to make those connections than it used to.

And, and that is very normal. So whenever people talk about things like forgetting, the names, the, the words on the tip of my tongue, or I lost my keys, or I can't find my keys, or I just wish that I could be quicker and sharper. Unfortunately, those are pretty normal. That's part of normal cognitive aging.

When we start to be concerned or really start wanting to hear a little bit more about those symptoms is whenever someone's cognitive changes actually start to impact their daily functioning. So, for example, rather than just, losing the keys for, you know, thirty minutes, an hour or so, it's more that someone loses their direction or their-- where they're going while they're driving.

They get lost while driving or, maybe you put the, the ketchup in the freezer or something, rather than that it's leaving the stove on. And so it's this much more meaningful, impactful, impairment of our independent cognitive functioning that we really start to, to be concerned about.

And, and, and, and there's a lot going on there we can talk

about

Melanie (Host): Yeah, I mean, it's pretty scary. I mean, even those little things you were talking about can be scary. We all get scared, and we've heard this term dementia. We also hear Alzheimer's disease. Can you just tell us a little bit about this umbrella that the disorders of cognitive function really exist underneath?

How is dementia and Alzheimer's different? How do they go together?

Robert Wiggins, MD: Yeah. So, the way I like to look at it is the larger umbrella would be cognitive impairment. And we really have two major, areas where you can kind of fall into, and one is called mild cognitive impairment. What that means is that on a test, you may have some impairment of your test numbers. When we really kinda grill you hard, you have some issues, but you're not necessarily having impairment of your independent cognitive functioning.

That's mild cognitive impairment. Now, once someone's also has impairment of their daily functioning, so they have more trouble with a checkbook or they, have trouble with cooking, they can't shop, that becomes more impairment of cognitive function, and that's when we go to a term called dementia.

Now, you mentioned one of the many types of dementia called Alzheimer's disease. Alzheimer's disease is a type of dementia, and there are others. So for example, one is called Lewy body dementia or dementia with Lewy bodies. Another one is called frontotemporal dementia. There's a vascular dementia.

There's a wide swath of different types of dementia, but the thing that links those dementias together is they all have impairment of independent cognitive functioning. And then, uh, once we've kinda decided, oh, this person has dementia, then we start the work to try to figure out, well, why? What, what, what's the cause here?

Is it one singular cause or is it multiple causes? And that starts to impact what we can actually do to try to help people make them feel better, and in a few cases, try to slow down that progress, that progression

Melanie (Host): And we'll get into that in a minute, but how do you determine what's going on, Dr. Wiggins? Is, is this a one-time pattern when you're doing an evaluation? Is this something that takes time to diagnose? Is there a test? Does it show up on CT scan? How do we know if it's actually, you know, mild cognitive impairment or dementia or turning into something more serious?

Robert Wiggins, MD: typically we would be able to determine mild cognitive impairment versus dementia probably even in one visit. that's something that we can do based on testing in a conversation. When we're looking to figure out the more, uh, more kind of advanced specifics of what the etiology or what is the cause of the dementia, that may take a few extra tests and a few extra visits, we'll say.

And what I mean by that is this. It's, it's not necessarily always easy to determine just by one brushstroke what the picture is. Sometimes we have to look at several brushstrokes, and so that could be an MRI of the brain. That could be different blood tests. More importantly perhaps, there is also a, what does your family say?

What have they noticed is going on? What were the first symptoms that you had? Oftentimes these different types of dementias, though they end up looking very similar the more advanced they get, they start very differently. So someone who has trouble with or who's developing Alzheimer's, they're gonna definitely have that short-term memory issues.

They're also gonna start having some executive functioning issues, where other conditions may not have the same. They may actually start with other issues. You may have something called hallucinations when you're seeing something that other people don't see that's not actually there earlier on in your course.

At the end of all dementias, everyone can have hallucinations, but at the beginning, a lot of these dementias start very, very different. So that, that's the important part of really trying to get at what's the cause, and it's how did it start?

Melanie (Host): So, it's really a lot of evaluation and determination by you as a neurologist and our physician figuring out all of these patterns and those changes. Now, if we notice these things in ourselves or in a loved one, which happens quite often where we start to notice in our elderly parents some things going on, what do we do?

When does it become that conversation with the doctor? And what if the person that we love that's experiencing these things that we say, "Mom, you know, I'm noticing this or that," and they don't really want to get help. What do we do in these kinds of situations?

Robert Wiggins, MD: Yeah, th-there's a lot of points there. The, the first thing that I would say is if you or others are noticing cognitive troubles, I would start taking notes. And what I mean by that is it's so, so often in my clinic when someone comes in and says, "Oh, there's so much I wanna talk to you about, but I can't remember what it actually was.

I can't remember the stories, the examples." And so the strong recommendation would be to say, "Go ahead and start writing down what you're noticing." Don't just write down memory issues. Write down what you mean by memory issues. I, kinda laugh 'cause I think I get on my patient's nerves by asking, "What do you mean by that?"

And then, "What, what do you mean by that? Really, what are the specifics of the situation?" So start taking notes. Then the typical next step is to go to your primary care physician or your primary care clinician and say, "Hey, here is what we're noticing." That primary care physician or clinician is gonna start saying, "Okay, well, are there any other non-dementia things going on?"

They're gonna look at your medication list to try to see if there are any medications that are causing troubles. Oftentimes, there are medications that are kinda blunting our cognition. Maybe they're making us more sleepy and not really allowing our body, our brain to work at its best. So that could be medications.

Also, things like depression and anxiety can really get in the way of our brain functioning. If you look at it like this, if, if our brains are like a computer, they can only take on so much at a time. And then you throw on really a meaningful, like anxiety or depression or stress, it's gonna be harder and harder for the brain to actually function on its normal, normal levels.

And that does not necessarily mean you have dementia. It means that there might be things getting in the way. So that's the role of the primary care, clinician to look into these things. Typically, they will also check your thyroid and your B12 levels. That is the sign of a good primary care clinician or primary care physician, that they're looking at those because those are what the primary care associations really recommend the primary care doctor check to make sure that those are not contributing.

They'll check B12 levels, thyroid levels, depression, anxiety medications. If we can't find an answer there, that's typically the time whenever they will refer to a neurologist. And that's when you really wanna come in with that list, and that's when you're gonna probably get a picture of your brain, an MRI.

You can get a more in-depth, a more meaningful cognitive evaluation or cognitive screen. And we're really trying to figure out the question of, "Hey, what is actually going on here? Is it actually a dementia-like process, or is it more just what we call normal cognitive aging?"

Melanie (Host): If the person that we love doesn't wanna come see you, do you have any advice for that conversation?

Robert Wiggins, MD: I think that's partly why it's really important that a primary care physician is actually checking, uh, cognition every year. And so we, we oftentimes by doing those kind of annual, uh, scheduled regular screening exams at primary care, we can start to pick up on some early things. Otherwise, if someone still doesn't want to go to see the neurologist, what I like to do is say, "Okay, well, no, l-let's-- this is just part of a normal process.

you're 80. We're gonna go get your memory checked. That's what we do." Or I sometimes say, "Well, maybe you go get your memory checked too. Have your memory checked, and then have their memory checked." It could be kind of viewed as part of the, um, the issue. I also sometimes recommend caregivers say something like, "You know, maybe you don't have a problem.

But let's just go get it checked, and if, if you're sure that you don't have a memory problem, prove it. This is your time to shine, right? You can-- They're gonna, they're gonna assess it." And, and I think that's important is, trying to not necessarily be adversarial, but say, "Hey, let's-- Yeah, okay, maybe you don't.

Let's go see. You know, I'm concerned, but maybe I'm not a doctor. Let's, let's get that taken a look at." And, and I think it's important that we're really trying to focus on this idea of it, it's not about me, i-it's about you. I, I want you to have the best quality of life. I want you to be with it. I want you to enjoy time with your grandchildren.

You know, in your last years of living, I want them to be great. Let's see what we can do about it to make your

life even better

Melanie (Host): Those are all great suggestions. I went myself and I messed up to have a cognitive test and I messed up the box. You know, the 3D box. And I got home and my kids were like, "Really, Mom?" 'Cause I was going like this, you know, and they're like, "Two things, connect, connect." I'm like, "Oh." But otherwise, I did pretty well.

Now, when we think of these actual conditions, Dr.

Wiggins, are there treatments? Are there-- You mentioned earlier, can we slow down progression? Tell us what's exciting in your field right now that can help people with whether it's slowing it down or just some of those symptoms that go... And then there's comorbid conditions that go along with some of these cognitive impairment disorders

Robert Wiggins, MD: Yeah. Could we talk about maybe what to do before you even have an issue? Because I think that's a really nice place to start, because we all potentially will have cognitive issues or dementia in the future. We're all, we're all potentials, right? And so what we should do in the here and now is focus on cardiovascular exercise, a good nutritious diet, particularly the MIND diet, M-I-N-D, that's very important.

Staying very, cognitively active, so not just watching TV, but really challenging the brain. This is the time when most people ask about crossword puzzles, Sudoku, et cetera. All those are good, but we really like to say, got to be engaged. So not just doing the crossword puzzle, but like interacting socially, going to events.

You know, really trying to s-stay up with all the things going on at work. That's cognitive engagement. And then as you mentioned, comorbidities, really making sure that you're following with your primary care physician, because making sure the blood pressure is checked, diabetes numbers are low, blood sugar, et cetera, those are all really important.

Those are all part of something called the brain health recipe, which is actually proven recently, uh, via a study, called the US POINTER trial from the, um, Alzheimer's Association, showing that these are the four things we can do to try to reduce the chance of cognitive impairment. Now, let's say then someone does in the future is diagnosed with dementia.

If it's Alzheimer's disease, we typically turn to a few different pills that will help the symptoms of Alzheimer's disease try to almost like be a little bit of an oil change, just to try to help the engine run a little bit better. and that's honestly all we had for a long time. But here in the last few years, we have much more exciting new things going on.

There are actually two different infusion therapies Rather than treating the symptoms, are actually trying to slow down the progression of Alzheimer's disease. So unfortunately, we know that Alzheimer's disease does worsen. But with some of these therapies, we can try to slow down that worsening by up to about a third over about 18 months.

And the important thing there, Melanie, is it's not just, oh, you'll do better with the box, or you'll do better with the testing. It's that life can be better, that you'll be able to be more tuned in, more engaged. That's more high school graduations that people can attend. that's more hours, hours of pickleball people can partake in.

That's more good life that we can live. And so it's not just about the numbers. It's not just about the study. It's about giving people more life. And that's really the role of these therapies to try to help with Alzheimer's disease, really try to slow down the progression

Melanie (Host): Wow, that was really some great advice. And when we think about the brain health that you were talking about and lifestyle, cardiovascular, all the things that go along with it, you know, we need to stop looking stuff up all the time when we can't come up with the word or the actress or the name of that movie or the, the song name.

We always go right to the internet and look something up, and I'm trying not to do that these days. I'm trying to make my gray matter work a little bit harder in there and say, "Okay, I gotta-- W- w- what was that? I gotta come up with it myself." So I think that your advice is right on, that we really need to work that so we can attend those functions.

Now, one of the things that I feel is so important when we think of these disorders, Dr. Wiggins, is the caregivers, because as these progress, whether it's Lewy body or Alzheimer's, whatever it is, these take an incredible toll on the caregivers because there's, there's agitation that goes along with it.

There's, you know, I mean, there's so much that is heartbreaking to watch someone go through, but the caregivers themselves, it's tough, man. So give us some advice for those people.

Robert Wiggins, MD: I think one of the first things that we like to recommend when someone has been diagnosed with dementia, particularly the caregiver, is let's start asking the question kind of who is your team, right? And so rather than having to find a team in a few years when things may be worsening, go and find your team now, right?

That team, of course, is made up of the doctor, hopefully the clinic's nurse, a case manager, social worker. Those are all things that we are really trying to put in place. But it's also, okay, are your children, for example, do they live close or do they live far? Are they gonna be able to help at nighttime, or are they gonna only be able to help with, like, phone calls?

Local friends, church members, friends, family, that kind... Those are the... We need to try to kinda create that, that team early on. The other thing, and we talk about this a lot, of course, the, the typical phrase is you can't help others before you help yourself. And so going back to that brain health recipe, even for the caregiver trying to focus on, hey, make sure you're getting good exercise, make sure that you're sleeping well, make sure that you are eating well, all those things, because you gotta take care of yourself.

You gotta make sure that you yourself are not developing, um, you know, issues. And I think that's a good, a little test, so to speak, of are you able to do these things

yourself? Now, it's always fine to ask for help, and I really recommend, caregivers start practicing asking for help.

Asking for help is not a sign of weakness. It's a sign of strength because you know what your loved one, what your husband, what your wife, what your, your father, mother needs, and you know that you're not able to provide that. And it's actually a good thing to try to ask for help and get them what they need because it's something you 
need too.

Melanie (Host): hear. hear. That's all really great advice. And we do have to put on our own masks, as it were. We have to take care of ourselves, and especially women. We're the caregivers to society, and if we don't care for ourselves, we're not going to be able to care for those we love. A- and if it's us, then we certainly have to do all the things you've talked about.

Dr. Wiggins, what a great discussion we're having today. As we wrap up, for people that are feeling a little anxious, they're worried maybe it's genetic, runs in the family, give us some guidance, reassurance about these kinds of disorders a- and what you tell your patients every day as your best advice

Robert Wiggins, MD: Yeah. So one of the things I think most important is to really turn back to the science. Go to the things we know, follow the brain health recipe from the US Pointer trial. We know that and we rely upon that. That's really important. What we don't wanna do is make ourselves more anxious by just looking at every source, buying every supplement, buying every unproven treatment.

Those things won't help. I think the brain health recipe is a good place to start. I think also the thought here is this, is that we're not just trying to prevent dementia, we're trying to make our cognition better. And you said it earlier on, Melanie, the phones that we're using oftentimes are impairing our, our, our cognition, right?

They're making us, lose attention, lose our ability to think. And so the thought here is treat yourself like an athlete. Are you doing everything you can to try to make your athletic performance or your cognitive performance, your brain health performance as good as possible? Don't worry about the future.

Think about right now what you can do in the here and now to make your brain, to make your performance better. So that's sleeping, that's following the brain health recipe, that's putting the phone down for a few hours a day.

Melanie (Host): That is great advice. Dr. Wiggins, what a great guest you are. Thank you so much for joining us and sharing your incredible expertise for something that a lot of people think about, are concerned about, but you've answered so many questions today. Thank you so much for joining us. And to find 
a physician, you can visit novanthealth.org.

And for more health and wellness information from our experts, you can visit healthyheadlines.org. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. That concludes this episode of Meaningful Medicine, a podcast from the specialists at Novant Health.

I'm Melanie Cole.