E29: 7 Domains of Our Aging Brain

Welcome. Today, I'm worried about my aging brain. And in a questionnaire for women attending Midlife Women's Health Clinic, many women have, as their primary health concern, worry about their memory function.

I'd ask my patients what specifically worried them about their brain and they'd say they forget where they put things. I often reminded them that forgetting where you put your keys can be normal. Too much on your mind when you put them down, and you will tag that memory so you can retrieve it and the keys. But if you look at the keys and aren't immediately sure what they're good for, that's a problem.

So we're going to talk about the "7 Domains of Our Aging Brain" because it's on our minds.

So much is on our mind as we get older. It seems impossible that we could lose it, but we do. And if we don't, someone we know will. So let's start with the physical and intellectual domain together because, with the aging brain, they go together.

What is normal aging of the brain? Well, what we know is we follow people over time, or we compare her a lot of 40-year-olds to 50s and 60s and 70s in brain scanners. And what we find is that brain volume decreases over age. The weight of the brain decreases about 5% per decade starting at about 40, with increasing rates after 70. And the loss is both the number of the brain cells and the connection of the cells.

If you look at a microscopic picture of the part of the brain, it looks like a tangled, messy spider web with everything connected with little bitty lines. Aging causes these connections to unravel.

The frontal lobe and the hippocampus, the part of the brain specific for cognition and memory, shrink more than other areas. Our occipital cortex, the part that we use vision for, tends not to shrink too much. And the parts in the front of the brain, not the back of the brain, are the largest lobes in the brain and considered to be the center for human behavior, and emotional control, and our memory.

Now, some changes in thinking are common as women get older. For example, older people can be slower to find words and recall names. Proper names go first, like, "Oh, God, I just met this guy and I can't remember his name," whereas verbs tend to go later. This is not uncommon.

They may have memory problems such as short-term memory loss. "Where did I put my keys?" or, "What day was I supposed to have that appointment?" This is called episodic memory.

Normal aging is less likely to be semantic memory loss, loss of meaning. So you may forget where you put your keys, but you remember what keys are for. You may not remember what is the capital of Paris, but when asked what Paris is important for you'll say, "Oh, Eiffel Tower, museums. It's the capital of France."

We tend to have more problems with multitasking. "I'm going down the hall to dust the bedroom and stop to put something in the bathroom, put the laundry away. And what was I supposed to do in the bedroom?" That's not uncommon. And we experience mild decreases with the ability to really focus for a long period of time.

But there are problems with aging of the brain that make this process of the brain shrinkage and brain function decline much worse. And some of those things can be caused by inflammation or decreased blood to the brain. So high blood pressure, high blood sugar, diets high in calories and low in anti-oxidizing foods like brightly colored fruits and veggies, living in a chronically high-stress level, air pollution, and smoking of any kind, all of these can cause inflammation in the brain.

And these can result in a bunch of stuff that's really bad for the brain, not normal aging, which includes big strokes where a big chunk of the brain has died, or small strokes, small vascular dementia where you get demented because there are little areas that have died because you had little teeny strokes. And that makes up about 15% to 30% of dementias.

Alzheimer's disease, which can also have problems with vascular disease, but there's junk in the brain. There are protein tangles and plaques in the brain that are junk that all of our cells make, but normally we're good at cleaning it up. But if it builds up too much, it seems to be associated with a more serious decline in brain function, and this problem can make up about 40 to 70% of dementias.

And some people have vascular dementia and Alzheimer's disease.

Well, what's the role of menopause if women are more likely to have dementia and Alzheimer's disease than men? Is there a role of menopause?

Well, women in the menopausal transition complain of brain fog, and it could be associated with a drop in estrogen and more hot flushes and poorer sleep. But we're not exactly sure whether it's exactly hormones or because women's brains develop differently than men.

So whether it's hormones or not hormones, it's not clear that taking hormones dramatically decreases the risk of dementia, but there are some studies that suggest that it may be helpful.

So there's no cure for these causes of dementia. There are some medications, which might slow the progression of the disease in some people. And we're all hoping for something in the future. But there are lots of claims about supplements that can improve brain function, but very little scientific evidence.

So what are the protective behaviors? There are some that, started in midlife, seem to be associated with much more vigorous brains when you get older. Well, one is vigorous exercise, meaning the hard stuff, but not for too long. Small amounts of coffee. Not very much alcohol, just minimal drinking, but not too much. No smoking of any kind, a Mediterranean diet, clean air, and good friends. What is good for the heart is good for the brain.

There's good evidence that improving these brain habits starting in midlife can increase the functional longevity of your brain. It is never too late to start.

But eventually, many of us will need help. And this is another domain where women's lives differ than men. Not only do women have a higher risk of Alzheimer's, but women are also more often the caregivers, young and old women. Most but not all caregivers are women. And 25% of America's caregivers are millennials, adults 18 to 34.

In fact, 66% of all caregivers are women, and female caregivers devote as much as 50% more time providing care than their male counterparts. And caregivers who are older than 75 years of age tend to be the sole support system for their loved one.

Now, this is a thorny problem because the aging brain and dementia includes everybody. It takes a village. And I'm going to introduce Liz Garcia-Leavitt, who is a clinical social worker and health care educator at the University of Utah Department of Geriatrics, specifically in the aging brain care program.

Liz has practiced for over 16 years as a geriatric and medical social worker specializing in dementia. And she's passionate about improving quality of life for individuals with dementia and their loved ones.

Dr. Jones: Liz, thanks for joining us. You're going to help us with a hard problem, but it must be rewarding but heavy sometimes to take care of these women and their families. So welcome to the "7 Domains."

Liz: Thank you so much. It's a privilege to be here with you.

Dr. Jones: Well, let's start with the Social Domain. Can you talk a little bit about the frequency of Alzheimer's in women versus men?

Liz: Yeah. It is more frequent for women to be open to diagnosis, I think, more often than men. I'll have often a woman who comes into clinic and when she's saying that she's having problems, she may mention her husband also has memory issues, but they just couldn't drag him in to get worked up.

We do know that women do live longer than men on average, and we do know aging is one of the highest risk factors for developing dementia illnesses. So, as for exactly why, we don't always know why more women end up with this diagnosis.

Dr. Jones: I was wondering that myself. I wondered whether women have often covered -- I will use that word "covered" -- for their men, meaning they do all the stuff for their guys so their guys don't necessarily come to apparent need for diagnosis.

The women continue to provide care for them and do a lot of the stuff at home. Whereas if women can't do those kinds of things, they will be brought to care by their family members because they can't care for themselves, whereas often women are the caregivers for the men in their lives.

Now, it's not always men in their lives, but it may be one of those things like depression where women come in more often, but guys actually commit suicide more. So it's a difficult one.

Liz: Definitely difficult. It's a major life role. I often say it's one of the only roles in our life where we fall into it as opposed to choosing this aspect of our lives.

When somebody gets married or somebody has a baby, we throw them a shower, there's a transition period, and it's definitive where we say, "I'm taking on this life role." And caregiving is different than that. It's something where many caregivers don't even identify as being a caregiver. It's just, "I'm a daughter," or, "I'm a friend," or, "I'm a spouse. This is just what I do." And they don't recognize that, "Oh, I've started to now be the one who pays the bills. I slowly am the one who's now doing all the driving. Oh, Mom now needs help going to the grocery store, so I just add that to my list."

Just slowly over time, often people end up . . . Even they'll think, "Well, Mom just had to come out of the hospital. She'll just be with me for a couple of weeks and then we'll go back to normal." What often happens is that normal doesn't come and you end up with a new normal.

It is a major life change to suddenly have another dependent in your life where you are in charge of the physical and emotional and social wellbeing for another person. And it's not something that people think about when they're thinking of their own retirement years or their life plans.

Dr. Jones: Well, we're definitely going to get that when we get to the Emotional Domain, because I think sometimes having things land in your lap, even if you're the most gracious and loving of people, leads to a little bit of discouragement or anger or sometimes despair.

We do know that middle-aged or older women who provide care for their spouse are six times more likely to suffer from depression and anxiety than women with no caregiving.

Other physical tolls caregivers can have include high blood pressure, an increased risk of developing hypertension, and lower perceived health. And certainly, people who are caregivers full-time overnight often get less sleep, and that means that their immune function and their own cognitive stuff can be at risk.

So how do women fare as the caregiver person when they develop dementia? What happens when those very behaviors that we think are really good to protect you against dementia are accelerated when you're the caregiver? What happens when women are failing when they're taking care of others?

Liz: I think it is different for every person. Every caregiver is a little bit different. I tend to find the ones that struggle the most of making that transition from being the person who has always helped and always been the giver to suddenly having to receive help, I tend to find that those who are willing to give up control tend to do better than those who just continue to hold tight to their control as they're losing the ability to do things for themselves.

It's a really tricky thing. Many dementia illnesses inherently have changes in insight where the patient themselves often feels like, "I'm fine. I don't know why everybody is picking on me. I don't have any problem." And so that's one of the biggest barriers.

Often for children caregivers or spouse caregivers, when they're seeing a problem, but the patient themselves can't see it. And that's one of the biggest barriers to getting help.

Most of the time, if the patient themselves isn't knocking on our door saying, "I have a problem," they're humoring their family members. And often, that's what I will counsel people when they are getting a new diagnosis, is that there will have to be a certain aspect of learning to work together and learning to accept that humoring you may be as good as it gets. This person may never recognize all the things that you're doing for them as their caregiver or thank you for it. And it is a real challenge that comes together with the job.

Dr. Jones: Right. Well, in the Environmental Domain, I think about . . . First of all, I have to put a quick note because anybody who's listened to me more than once knows that I'm a clean air advocate. There's much information, particularly for women, that poor air quality is associated with a more rapid decline in cognitive function in older women. And when air is cleaned up, and we have had cleaner air in the last 20 years in some parts of the country, the rate of cognitive decline slows. So that's really great news.

But in the Environmental Domain, there are often changes in living situation, meaning people who've always lived and they know their home have to move. And if they're the caregiver living in their home, they may have to move because they can't do it with the person they're caring for anymore.

So what are the struggles that persons with dementia face when they change their home and living situations, Liz?

Liz: Well, especially with Alzheimer's disease, new memory and new information has a harder time sticking. And so often people will say, "Oh, we made this move and we saw a sudden change in our loved one." I often tell them it's not actually so much that the brain has changed, but it's because the environment has changed, and the routines and the old memories aren't there to bolster up what the person is doing.

So we do strongly recommend a familiar environment as long as you can. Often, it does get to the point where people can't stay in their environment because of safety or practicality and a move is necessary.

People will adapt to a new environment. It just may take longer than it would have in the past. I usually tell people, "Give any new move at least a month or two before you say it's a good choice or not."

But environments are really important. Often, patients have a hard time initiating activities. So being in an environment where other people are, where other people can say, "Hey, it's time for lunch," and other people can engage with you in activities and help you avoid isolation is often worth a move over somebody just staying in their home and being isolated.

So all these are factors with the living situation that need to be taken into consideration.

And it is a new normal for patients as well as their caregivers. If you're saying, "I'll just have my loved one move in with me, and we'll just share a home," you really need to recognize that that's a huge change for both of you and not a decision people should fall into lightly, because you're really becoming a full-time caregiver, a live-in caregiver. That's a full-time job in addition to what other jobs or family responsibilities you have. So it really should be something that you make a decision with your eyes wide open around.

Dr. Jones: Exactly. And I know before you came to The U, or is part of your many years of taking care of families around the issue of dementia, you've probably visited nursing homes and retirement facilities. How do things work with the caregiver who actually moves out of their home with their loved one who has got dementia, and so they now have left their home as well? Do you have any stories or ideas about whether you let someone go without you or you go with them?

Liz: It's such a personal decision. I have caregivers who've done both. And often, spouse caregivers get really attached to their loved one and so protective that sometimes even moving in to a care situation where there are built-in aides, built-in supports and activities, there's still a tendency of, "But I still have to do everything." And it's hard sometimes to convince them to trust the aides and be able to go . . .

Today, I was talking with a gentleman who they both moved into assisted living together. This was a caregiver who had been really involved in hands-on caregiving for over 10 years, and we're talking, "What are the things you'd like to do?" We're just trying to convince him that even being able to go to a church service for three hours would be okay to leave her with the aides and build up to that.

It tends to take over a lot of people's worlds. And being able to trust the environment, trust that other people can do a good job in loving and taking care of your loved ones is a leap of faith for a lot of our caregivers.

Dr. Jones: That's beautifully said. And I'm glad you brought up the example of a man bringing the care to his loved wife or a partner for a long time. I'm assuming that's what it was. Maybe it was a loved male partner, but men have been often very protective of their partners as they continued in the last years of their life.

I'm thinking about this business of changing environments, whether it's moving out of your home into a kid's or a friend's home, or moving into an assisted living. Knowing what you do know and how frequent Alzheimer's or any dementia is, how can people prepare financially? Is this something that you talk to couples when you see them early in their disease?

Liz: Absolutely. And the challenge is usually by the time you're already diagnosed, some of your options are off the table. The way our health system is set up, people assume, "Well, Medicare will just take care of that if I need care." And they don't understand that Medicare does not cover long-term care or care in the home of the type that people with dementia illnesses often need.

So these are among some of the most expensive diseases there are, and primarily is because the families themselves have to pay for the care. If people plan way ahead, you can get long-term care insurance, and many workplaces or individuals will get that on a private market. That's what long-term care insurance is for, is to cover this gap to pay for aides in the home or pay for assisted living that otherwise would not be covered by insurance.

I'd say maybe 5% to 10% of my patients actually have long-term care insurance.

For the vast majority, it's just looking at your savings and resources and finding ways to make those stretch to the care people need.

Dr. Jones: Are there financial counselors for this? When I think about the ways people can stretch their finances a little bit or how can they get assistance in terms of providing this kind of care, is that something you that within your context as a social worker can do, or do you recommend people to look for financial help if there is any?

Liz: I can definitely talk to people about the big numbers, what care usually costs per month and give them estimates. I don't usually know the person's financial situation when they first come to see me. And so part of that is having them trust me enough to talk in the general categories of where they're at.

And also talking about what are safety nets, things like Medicaid, which you have to make a very little amount of money and have used up all your resources towards care for that to eventually kick in as a resource.

So most people, we usually recommend starting with something as simple as having an aide come into the home for a couple of hours a week and then building from there. Not everybody needs assisted living, not everybody needs full-time care, but we talk about, "What's working right now? What's our Plan A, and then what's our Plan B if you do need more help? What's our Plan C if something happens to your primary caregiver?"

Knowing the stress it does put on the caregivers, there are many sad cases where the caregiver themselves passes away first. And so talking about the financial impact and also the physical impact of that.

We try to draw in larger family groups or build the network for people to make sure it's not all landing on one person. Often, there may be adult children or siblings or other people in the family who would be happy to support and help, but they're not always clued in to the severity of the situation. And so a big part of my job is to build up and do family meetings.

Dr. Jones: And we'll tell a story of a dear friend whose husband developed a kind of frontotemporal dementia, which tends to hit a little earlier. And when he was finally diagnosed, she did all the care for him up to the last several months of his life. Actually, we did a podcast on The Scope with her on long-term care or being a caregiver.

She's a relentlessly optimistic and a very wonderful, bright woman. And she said, "Well, I figured it was going to be $100,000 a year to give him the kind of care that I wanted, and I never had a job that ever paid that much. So I consider this the best paying job I've ever had." And I thought, "Wow, I never really thought of it that way."

But she took this perspective of what would it cost and could she do this job. And she did with a great deal of love and care. She gave her husband the kind of care she would have paid $100,000 a year for up until the last several months of his life.

So the costs really can add up. And some people who have the resources to try to do long-term care insurance say, "Oh, I just hate paying for something I might not use." Over 50% of people are going to be in some kind of assisted living for more than a year.

I try to tell people who are thinking about this or family members that say I can't afford it, I say, "I understand that. You should put this much money away in your own savings account then because it's pretty good chance you're going to need it for a while."

Liz: Absolutely. I have a long-term care policy for myself after working in this field just because it does give you so many more options. And that's really what it's about. You can save up money, you can use it, but the benefit of a long-term care insurance policy is that . . .

I find that if people have them, the guilt of using it goes down because it's kind of a use-it-or-lose-it policy. And so it can help people say, "Well, I guess it would really be great to have that extra help, that person who can come in and clean or somebody to take care of my yard or just somebody who can give us rides to places."

Recognizing that it's a benefit, that it's kind of a use-it-or-lose-it, I think, is actually really great for wellness for the caregivers, to give them permission to do that.

A big part of my job is giving permission for that anyway, but it makes a big difference. And from a caregiver wellbeing perspective, recognizing that you really can't do it all by yourself. I've been doing this over 15 years. I've yet to meet the superhuman who could do it all by themselves 24 hours a day, 7 days a week. Starting early with delegation and accepting help is huge.

Dr. Jones: It was the gift I gave my husband for our 50th birthdays. He didn't want it and I said, "This is the gift I'm giving you. We're both getting long-term care policies." He says, "Oh, I don't need it." And I said, "I'm just going to give it to you anyway. It's like all other gifts I've given you that you didn't really think you wanted. This one, you're going to want someday."

Well, getting back to the Emotional Domain, we talked a little bit about what happens to the caregiver in terms of giving up sometimes their identity perhaps or taking on a role. Luckily, it often happens slowly. So it's not quite like someone who's had a very bad accident and now has or someone who's a paraplegic or quadriplegic and is doing full-time care for them all of a sudden. It tends to come more slowly, but it's still sometimes a burden, a worry for the caregiver.

But how about the patient? The nature of losing your mind, the nature of dementia, is sometimes you lose your personality or the personality you that you worked hard to develop.

Liz: Well, the patient themselves, I think the most common emotion that they tend to display is frustration or anxiety. They may notice that there are some changes that are happening, they may notice that they get frustrated when they go to do something and they can't do it anymore, but it isn't inherently painful in a lot of cases.

When we look at somebody who's losing memory or losing ability, we often say, "Oh, if that was me, I would feel awful in the situation." But we don't look at a child and say, "Well, their quality of life must be much less because they have a different cognitive ability than they will have when they're an adult."

I like to think of dementia as kind of a different developmental state for a lot of people where they can have great quality of life as long as their needs are met. And the needs change as people get older.

You'd be surprised how stoic most patients are when they get a diagnosis. I've sat in the room, I've given these diagnoses over and over again. It's not something where people often have a huge emotional reaction to it.

I think that there's a tendency to project ourselves into, "I would feel that way if I had this diagnosis." But I think it's much better to just take the person where they're at, talk to them where they are at, see what they are feeling, and address it from there, instead of putting ourselves in their shoes.

Dr. Jones: Liz, that's one of the wisest things I've ever heard in terms of approaching someone whose cognitive ability has changed from the person they knew. And you're right, I would look and say, "Oh, I couldn't live like that." But they might be really happy to have ice cream and chocolate chip cookies for dessert, and that might be just great. Thank you for giving us that particular view.

As we think about the Spiritual Domain, I don't know if you think either spirituality or some kind of religious life is helpful in people with dementia or their caregivers. Do you have any thoughts in this last bit?

Liz: Caregiving and healthy caregiving comes down to a choice, and how you visualize your role. For some people, that is deeply spiritual, where they take on this role as an act of service and an act of giving to their loved ones.

And I think it's a beautiful thing to see when people really have just decided that this is the way they want to live their lives. They want to be the type of person who takes care of their loved ones no matter what. No matter what situation they're in, they dedicated themselves to love this person in whatever format that they are.

We often talk about the negativity of caregiving. I've had several caregivers come back and say, "It was hard, but it was one of the best things I ever did for my soul to actually have that role and have that gift of service to this person." Especially if it is a person that served you throughout your life, to be able to give back and give that as a gift to them.

I would never tell somebody they shouldn't be a caregiver if that's something they feel as a calling for them. And it is a huge gift, but I think it all comes down to that recognition of caregiving being a choice. If somebody doesn't want to be a caregiver, I would never want to try to guilt somebody into that role.

And if they're saying, "I just can't be this person to take care of this individual . . ." Sometimes our parents or sometimes our spouses have been people that have not been healthy for us, and trying to push myself into a caregiving role for somebody who may have been abusive, that's not healthy for either of us.

And so trying to find options and making people know that they're never stuck in this role, I think, is one of the healthiest approaches to take.

Dr. Jones: Liz, thank you. We will all be touched by dementia, a friend, a sister, a partner, or ourselves. And there are ways to keep our brain healthier by remembering that what's good for our heart in all of the 7 Domains is good for our brain.

Improving our physical, emotional, social, intellectual, financial, environmental, and spiritual lives can help our brains function better as we age and can help us as we're helping others. So we need to keep ourselves healthy and resilient as we care for and about others.

Really grateful, Liz, that you joined us today as we think about this. And for the care that you offer other families, thank you so much.

Liz: Thank you so much for the opportunity.

We will end with our "7 Domains" Haiku, as we always do.

Are you still in there?
The person I knew and loved
It would help to know

So thanks for joining us, for all of us who are listening. Join us wherever you get your podcasts, or listen to some other Scope podcasts. We'll see you again. Talk to you again. Bye-bye.