The Aging Brain
UT Health Austin neuropsychologist Jared Benge, PhD, ABPP, provides answers to the top 10 questions he gets asked about the aging brain
Written by: Rocky Epstein and Ashley Lawrence
Neuropsychology is a branch of psychology that is concerned with how a person’s cognition (the process of gaining knowledge and understanding through thought or experiences) and behavior are related to the brain and the rest of the nervous system. In other words, understanding how neurological processes, such as attention, memory, and language, influence the brain, which, in turn, influences how we think, feel, and behave.
In this webinar, Jared Benge, PhD, ABPP, a neuropsychologist in UT Health Austin’s Comprehensive Memory Center, provides answers to the top 10 questions he is asked by patients in the clinical setting about the aging brain.
A neuropsychologist is a psychologist who specializes in evaluating behavioral and cognitive changes that results from central nervous system disorders, such as Alzheimer’s disease, dementia, memory concerns, and mild cognitive impairment.
“A neuropsychologist holds a PhD,” explains Dr. Benge. “Just just like how your physicians go and get a general medical school degree and then specialize in a particular area, neuropsychologists do the same thing. We attend graduate school in general clinical psychology, and then we specialize. A neuropsychologist is a psychologist who specializes in measuring cognitive processes. We measure things like memory, attention, and language, and then we use those measurements to help guide diagnosis and treatment planning for people that have neurological conditions.”
“When you’re dealing with conditions that affect the aging brain,” continues Dr. Benge, “it really does take a team of people to set up diagnosis and treatment plans. At UT Health Austin’s Comprehensive Memory Center, when we’re addressing these problems that can come up with aging, we talk a lot about the care team, because each of us bring our own specialties to the table to help arrive at diagnosis and treatment plans that meet patients’ specific needs.”
The Comprehensive Memory Center care team includes:
- Neurologists who specialize in the nervous system
- Psychiatrists who specialize in the treatment of mood and cognitive changes
- Neuropsychologists who specialize in measuring how the brain works
- Nurse practitioners who specialize in managing a patient’s health problems
- Speech-language pathologists who specialize in behavioral treatments for cognitive and language changes
- Social workers who specialize in helping patients and caregivers learn strategies for managing health and gaining access to the care they need both in the community and at home
- Clinical pharmacists who specialize in how medications work together to help or hinder how the brain functions
“We also work with psychometrists who administer and score cognitive tests and research assistants who are committed to studying and developing new treatments,” says Dr. Benge.
“When I explain dementia, it really does boil down to two things,” says Dr. Benge. “First of all, a change in thinking has to occur that’s not attributable to the normal aging process. That change in thinking has to make it harder to carry out day-to-day activities that the individual used to be able to do. Change is inevitable whenever it comes to the brain. Your brain is just another part of the body, and just like the rest of your body, it changes with age. Common changes with aging include experiencing a slower processing speed and more difficulty multitasking. However, when you start to experience changes in memory and attention, you have to stop carrying out your day-to-day activities, you’re making more mistakes in your day-to-day activities, such as forgetting to pay the bills or mistakes while driving, or in later stages, you begin experiencing problems with more basic tasks or problems remembering to bathe or shower, that gets our attention.”
“Secondly,” continues Dr. Benge, “you also have to rule out other causes that can lead to those same experiences. The brain is the end result for many different medical processes, as almost anything that affects your body can affect your brain. Before you can diagnose something like dementia, you want to make sure there aren’t any other health conditions causing these changes in thinking or changes in day-to-day activity.”
“Another term you’ll sometimes hear is this idea of mild cognitive impairment (MCI),” explains Dr. Benge. “The difference between MCI and dementia is that in MCI, you have measurable changes in thinking. So again, you’re having more problems than we would expect based on your age, but you’re still able to carry out all your day-to-day activities. If you have measurable thinking problems, but they’re not really interfering with day-to-day tasks, that’s when we use an MCI label. If you have measurable problems in thinking and they’re making it harder to do day-to-day activities, that’s where we would use a dementia label. MCI has become a hot area of research and practice, because whereas all people that get dementia will have passed through a mild cognitive impairment phase, not all people with mild cognitive impairment go on to develop dementia. This is where that earlier detection is getting a lot of traction behind it as a place we want to possibly intervene at or at least be monitoring closer.”
If you’re fully functional today despite some memory problems, you’re likely looking at no more than mild cognitive impairment. If complicated day-to-day activities, usually things like medications, driving, and finances, are impacted, that’s a milder stage of dementia. While the stages of dementia are often referred to as the early, middle, and late stages, there are actually seven stages of dementia. Staging of dementia is based on the severity of the dementia and how well a person can live in their day-to-day environment.
The 7 stages of dementia:
- Stage 1: No Cognitive Decline: This person has not experienced any memory-related issues and overall is mentally healthy. They have no problems with judgment, communication skills, or daily activities.
- Stage 2: Very Mild Cognitive Decline: Occasional lapses of memory occur but aren’t noticed by family or friends. Studies show that half of all people over age 65 begin noticing some cognitive difficulties, but at this stage these difficulties are considered a normal part of the aging process.
- Stage 3: Mild Cognitive Decline: At this stage, mild changes in memory, behavior, or the communication skills are noticeable. There may also be difficulty with recalling names or words, planning and organization, performing daily tasks, misplacing objects, and forgetting things that were just learned.
- Stage 4: Moderate Cognitive Decline: Cognitive impairment symptoms are more obvious at this stage and are easily detectable by a physician or therapist. There may be some confusion when completing tasks, such as cooking, driving, or shopping. Recent events or conversations may be forgotten, and there may be trouble with handling finances. Social withdraw, mood swings, or depression may also occur.
- Stage 5: Moderately Severe Cognitive Decline: Assistance is required with day-to-day activities at this stage. Severe memory loss, disorientation over what day or season it is, and decreased personal hygiene skills are experienced. However, it is common to still recognize significant family members.
- Stage 6: Severe Cognitive Decline: The ability to recognize family is no longer present at this stage, and there are noticeable personality changes, such as paranoia, suspiciousness or extreme anxiety. Help is needed with many basic daily tasks, and constant supervision is required.
- Stage 7: Very Severe Cognitive Decline: Communication has become very limited and help is needed around the clock for all daily personal care.
“Dementia has to have a cause, and a lot of things can cause dementia,” explains Dr. Benge. “Dementias are usually caused by microscopic proteins or structural changes in the brain or a combination of both. There are two proteins, the beta-amyloid and tau, that cause the most typical and the most common dementia known as Alzheimer’s disease, which is usually marked by having a lot of forgetfulness with other changes in thinking later. There is some variance. Sometimes, those proteins appear on the sides of the brain in the temporal lobes, which is where memory and language happen. Other times, those proteins will pop up in the back of the brain and cause visual problems first. If they pop up in the front of the brain, they can cause all kinds of behavioral and multitasking difficulties. However, those proteins typically accumulate in the memory parts of the brain.”
“Another protein that can accumulate in the brain is what we call Lewy bodies,” continues Dr. Benge. “Lewy bodies are actually clumps of something called alpha-synuclein, or synucleinopathies. These are the proteins that cause Parkinson’s disease. Sometimes, those Lewy bodies start in the thinking parts of the brain first, which causes Lewy body dementia. Vascular dementia is also very common. As you age, your brain is full of these teeny tiny little blood vessels, and individuals who have risk factors for heart problems, such as high blood pressure, hypertension, and hyperlipidemia, can clog off those little blood vessel changes in the brain. This happens to all of us as we age; however, some individuals get more than others, which can cause thinking problems and lead to vascular dementia. People who have experienced strokes and never fully recovered from the damage to their thinking skills may also be diagnosed with vascular dementia. Frontal temporal dementia involves changes to the temporal and frontal parts of the brain that cause changes in speech, personality, or behavior. This usually occurs in individuals in their 40s, 50s, and 60s.”
“If there’s a concern, schedule an appointment with your primary care provider,” says Dr. Benge. “You want to begin the process as quickly as possible to rule out other treatable conditions. Once your primary care provider has ruled out all other possible conditions, then you may receive a referral to a specialty clinic.”
“Patients seen through UT Health Austin’s Comprehensive Memory Center undergo a medical evaluation by one of our neurologists, psychiatrists, or nurse practitioners,” explains Dr. Benge. “We may also try to measure the patient’s cognitive changes depending on what the difficulty is as well as order scans of the brain to make sure there is no kind of structural changes occurring in the brain or any blood vessel changes that might influence cognition. Family members often meet with a social worker so we can better understand any day-to-day needs that the family may have. Once all that information has been gathered, the patient’s entire care team sits down as a group to go over all the information and determine what the best treatment options would be for that specific patient. Then, we conduct a follow-up visit with the patient and their family to go over everything together.”
“Patients may also be sent for a CAT scan or an MRI,” continues Dr. Benge, “and when that report comes back, it might say something like ‘an unremarkable scan for age,’ or ‘mild atrophy and mild white matter disease.’ Something to keep in mind about CAT scans, MRIs, and other forms of imaging in a dementia workup is that imaging is most helpful at ruling things out. We want to rule out the possibility of the patient experiencing silent strokes, a silent brain tumor, or any sort of enlarged ventricles that can be seen with some conditions. While these forms of imaging can help us rule some conditions out, they cannot diagnose a condition, such as Alzheimer’s disease, except under a very specific set of circumstances. You may also hear about positron emission tomography (PET) scans and amyloid PET scans. These have been around for a while and are increasingly used in diagnostic workups for cognitive impairment. However, they also haven’t really replaced the standard of care, and there are things that we usually order in addition to these or if we’re about the unsure about the diagnosis based upon results from the workup.”
“A genetic component is more concerning in earlier onset cases, those individuals who pretty obviously are experiencing declines in thinking and problems with day-to-day activities in their 40s, 50s, and early 60s,” explains Dr. Benge. “This is due to three genes in particular. There’s what’s called APP, an amyloid precursor protein, and then two genes, PSEN1 and PSEN2, that are associated with those early onset conditions. If you’re noticing changes in your thinking, you want to make sure your doctor is aware of that family history.”
“Later onset conditions,” continues Dr. Benge, “where individuals are experiencing memory problems in their late 60s, 70s, and 80s do have a genetic risk factor there, but it’s not a sure thing that you’ll develop dementia if someone in your family has late-life dementia, even if you have very similar genetics.”
“We don’t generally recommend genetic testing routinely, except with a few conditions,” shares Dr. Benge. “With commercial DNA tests coming out, one of the genes for late-life Alzheimer’s disease, APOE e4 is routinely screened for. But again, because that gene only gives a relative risk, it is not really diagnostic in its own right. I generally steer people away from pursuing on their own genetic testing. Or, if you’ve had it and you’ve seen it as part of a commercial genetic test, again, I wouldn’t necessarily lose a great deal of sleep about that, because it’s a risk factor among a lot of risk factors. For example, APOE e4, which is the most common gene that you’ll see thrown around for late-life Alzheimer’s disease, confers a relative risk. Therefore, the average 65-year-old has about a 2% risk of developing Alzheimer’s. And that may go up to 2.5% if you have the APOE e4 gene. That’s a 30% increase, but it’s a relative increase. It’s not quite what some of the headlines or some of the test makers might make you think.”
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“Over-the-counter memory supplements aren’t generally what we recommend,” shares Dr. Benge. “Mainly, because there isn’t a ton of evidence to support them or the evidence that is out there is biased, either due to the type of study or from trials with questionable endpoints and those sorts of things.”
“The role of nutrition in which what you eat and how you manage your health, particularly your heart health, as heart health equals brain health, is super important,” explains Dr. Benge. “And we know that if your body is lacking certain nutrients, particularly vitamin B12, or if a defined abnormality exists, by all means, supplement them, as these deficiencies can influence your brain.”
<br>“The problem with a lot of supplements,” continues Dr. Benge, “is that first of all, your gut likes to get to homeostasis. In other words, if there’s too much of something in your bloodstream or in your gut, filters within the body tend to try to filter that stuff out so it doesn’t get in. Or, you have things like the blood-brain barrier that actively tries to keep stuff out of brain. So, not everything may pass over and influence the brain. It’s actually hard to get stuff to pass into the brain. That being said, there’s a lot of research on this area. There are some things like vitamin E and antioxidants that either alone or in combination with other dietary things that may have some benefit, but those studies are really hard to conduct because so many other factors go into it, such as diets, exercise, and living a healthy lifestyle.”
“Earlier this year, there was a lot of excitement about a new FDA-approved medication called Aducanumab, or Aduhelm,” says Dr. Benge. “These are really exciting medications that have been trialed and developed over a number of years, and they focus on helping the brain clear one of those two proteins that cause Alzheimer’s, beta-amyloid. These Aduhelm medications help kind of clear that amyloid out of the brain, and they do a good job of clearing amyloid out of the brain.”
Aduhelm is an amyloid beta-directed antibody used to treat Alzheimer’s disease under the accelerated approval pathway, which provides patients with a serious disease earlier access to drugs when there is an expectation of clinical benefit despite some uncertainty about the clinical benefit.
“The only problem,” shares Dr. Benge, “is that in the initial data and trial designs, there were a lot of unanswered questions, because the trials were stopped early. Questions such as: How much benefit can someone actually expect? Who is the right candidate for Aduhelm? What are the side effects and risks associated with Aduhelm?”
“Some of the biggest unanswered questions are: Who is going to pay for it, and how it was going to get reimbursed?” continues Dr. Benge. “I’m excited about having new tools in the toolbox, but there’s still a lot more data that needs to be gathered to help us figure out who is the right candidate for receiving this form of treatment and how do we properly counsel that person about what to expect.”
“The six pillars of brain health are the six most important things that can really make a difference in your cognitive health,” shares Dr. Benge. “And that means increasing your risk of avoiding cognitive impairment or dementia, or even reducing your risk of decline or slowing the process down.”
1. Physical Exercise
“Your brain is a part of your body, and when you exercise, you release a whole cascade of chemical changes in your brain that seem to be beneficial,” says Dr. Benge. “There was a study out of Pittsburgh that assigned older adults to two different groups. One group carried out their usual activities, while the other made an effort to add in 30 minutes of walking 3-5 times a week. At the end of the six-month follow-up, the group that was assigned extra walking showed growth, expansion, and bigger hippocampi, the memory parts of the brain. They changed their brain, as opposed to the other group, among which you saw the slow loss of those volumes in the brain.”
“Physical exercise is beneficial for the brain, and it doesn’t have to be extreme,” continues Dr. Benge. “One of the primary things you can do to help your brain is to use your body.”
<br> 2. Food and Nutrition
“Eating your veggies and reducing intake of processed foods have protective effects on the brain as well,” says Dr. Benge.
Small changes to your diet can make significant impacts on your health, especially when those changes take place consistently over time. Set SMART goals, or goals that are Specific, Measurable, Achievable, Relevant, and Time bound. Setting clear, trackable, reachable, realistic, and carefully planned goals will set you up for success.
<br> 3. Managing Your Health
According to the U.S. Centers for Disease Control and Prevention (CDC), 6 out of 10 Americans have a chronic disease, many of which are preventable. Heart disease, diabetes, obesity, and even certain types of cancer are among the various chronic diseases that can often be prevented, delayed, or alleviated to extend a person’s quality and longevity of life. It’s important to make healthy choices every day to invest in your long-term health
“Heart health equals brain health,” shares Dr. Benge. “Managing aspects of your health, such as hypertension and diabetes, are important factors as well.”
Sleep allows your brain to process information and consolidate memories While much of the science of sleep remains a mystery, one thing is certain – the disruption of sleep pattern, alternating between quiet sleep and REM sleep, increases your levels of stress hormones and impairs thinking.
Poor sleep habits and sleep disorders are potentially associated with an increased risk of developing mental health diseases like depression, ADHD, bipolar disorder, and anxiety or worsen the impact of existing conditions.
“As your brain ages, it’s important to practice good sleep hygiene,” says Dr. Benge. “Better sleep habits are associated with better long-term cognitive impairment and reducing your odds of long-term cognitive impairment.”
<br> 5. Mental Activity
“Use it or lose it,” says Dr. Benge. “Actively engage your brain by participating in activities such as reading, games, puzzles, and brain teasers”
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<br> 6. Social Interaction
“Brains need other brains, and people need people,” shares Dr. Benge. “it’s important to maintain those social relationships, as those that are engaged socially tend to have less risk of developing dementia. And those that do develop dementia tend to decline at a slower rate.”
“When you get on an airplane, the staff gives you an obligatory safety lecture at the beginning of the flight, saying, ‘If the oxygen masks deploy, put on your own mask before you try to help the person next to you,’ says Dr. Benge. “This is hugely important for caregivers as well. By taking care of yourself, you’re better able to take care of the person who needs your support.”
<br>“If you’re a caregiver, one of the hardest skills to learn, especially if you’ve been married to somebody for 40 or 50 years and you’ve lived your life together and you’re seeing these memory changes firsthand, is having to reexplain things or redirect a conversation,” shares Dr. Benge. “Somebody who has a true memory problem tends to forget what they forgot, and saying things like, ‘We already talked about that, don’t you remember?’ or ‘Why are you saying that, that doesn’t make any sense,’ those sorts of statements may make you upset because you’re upset by the situation, but it also can make the person who has the memory problem upset because they don’t remember it and they get defensive about those sorts of things. And then as that situation escalates, it causes more confusion and more irritability to set in. If you’re stuck in one of those loops of kind of repetitive questionings or forgetfulness, sometimes it’s helpful to move the conversation or do redirection, redirect to a different topic. One of the weird things about the brain is that old memories, memories from 50 years ago, are easier to process than new memories, things from 15 minutes ago. So, having photo albums or a tablet with older pictures on it and saying, ‘Oh, okay, well we don’t need to talk about that now. Hey, I came across this picture the other day from back in the day, let’s talk about that.’ Try to get the brain back into comfortable territory of things to talk about. It can sometimes be a helpful way to diffuse those sorts of conversations.”
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