What is considered “normal” memory loss versus dementia? 

Intro Speaker:  

Hello, and welcome to Matters Beyond Wealth with your host, Leanne Kaufman, president and CEO of RBC Royal Trust. For most of us, talking about subjects like aging, late life, and estate planning isn’t easy. That’s why we’re going to help get the conversation started on this podcast while benefiting from the insights and expertise of some of the country’s top experts. We want to bring you information today that will help to protect you and your family in the future. Now, here’s your host, Leanne.

Leanne Kaufman:

It’s January as we record this, and that means it’s Alzheimer’s Awareness Month, which really serves to highlight all forms of dementia and cognitive impairment. We have discussed in previous episodes [on] this podcast, the staggering statistics around aging Canadians and the growing impacts of dementia on our population. While there is a lot of information out there about dementia, there is also a fair bit of misinformation and not everyone understands that some of our risk factors may be controllable, including our lifestyle choices. That’s why I’m so excited to speak to our guest today who is here to help us understand this complex topic and what habits we can begin today to protect our cognitive function for tomorrow.

Hello, I’m Leanne Kaufman and welcome to RBC Wealth Management, Canada’s Matters Beyond Wealth. With me today is Dr. Howard Chertkow, chair in Cognitive, Neurology and Innovation and Senior Scientist at Baycrest and Rotman Research Institute. Dr. Chertkow has too many other credentials and roles in his long and impressive CV for me to mention them all. His major areas of research focus in early diagnosis of Alzheimer’s disease and certain of its therapies. He is a prolific author and his expertise is recognized frequently by others who cite his work. In fact, Stanford University has listed him in the top two percent of cited researchers, so there is no doubt he’s extraordinarily well positioned to speak on this topic.

Dr. Chertkow, it is an honor to have you here with me today to discuss some of the risks, the myths, and what we can do to increase our brain health and why this definitely matters beyond wealth.

Dr. Howard Chertkow:

Thank you, Leanne. I’m delighted to be here with you to talk about a favorite topic and I hope it’s going to be of interest to your listeners.

 Leanne Kaufman:

I’m absolutely sure it will. So, for those listeners, let’s start with a general overview. How do you define “normal” memory loss versus dementia, and maybe add onto that, what are some of the causes and types of dementia and when should we be worried that we’ve transitioned from normal into what actually may be medical?

Dr. Howard Chertkow:

Good question, we’re talking here about aging and we’re all aging and the alternative is not very good and we all hope we’re going to continue to age and age well. But as everybody knows, aging is accompanied by changes and changes in how fast you move, changes in your eyesight, changes in every aspect of your body, even things you’re not aware of, and changes in your brain. So the question becomes, well, what is normal aging? And this you’d think is an easy question, but it’s not because some of the things we used to call normal we now realize are an illness, their pathology, they’re a kind of a sickness. There was a time when getting blurred vision as you got older was just considered normal. Now we know it’s cataracts, this can be treated, we can get [our] eyesight back even better than it was when you were 20.

So what about brain aging? Well, there are changes that most people notice when they get into their 50s and 60s. For example, when you get a list of things to get at the grocery store, and when you’re 20, you just remember five or six or seven things, you go and pick them up and bring them home. When you’re in your 50s and 60s, people start saying, “Okay, I’ve got four of those items, what was the fifth item?” This is called episodic memory, retaining information. We’re just not as good at it when we’re over the age of 50 and 60 then when we were 20.

Visual memory, finding your car in a parking lot. I used to look up my window of my office I could see the parking lot, the young doctors in their 20s would go out and go immediately to their cars, then you’d watch the doctors in their 60s go out and wander around the parking lot trying to find their car, it just wasn’t as easy. These are people who felt they were normal and they would be called normal because norms, you compare to people your own age for this reason, it is normal to have mild decline in all aspects of what we call episodic memory.

On the other hand, there are parts of your brain functioning, which actually are better when you’re older. What we call semantic memory, your knowledge of the world, your judgment, your general knowledge of things is better when you test people in their 60s than people in their 20s. Not surprisingly, your wisdom in a sense. And so it’s only part of your brain function, part of your memory function which is affected normally.

Now, it becomes a question, what is normal? And the “normal” is, there’s a wide range. There are people who had a perfect memory when they’re 20 and a perfect memory when they’re 70. There are others who are more average who forget a few things and a few things more as they get older. What we count as abnormal memory loss is really the clear cutoff is when you can no longer do things you used to do because of your memory, and that really is what is dementia—is the clear decline in your memory function. People complain of it. We test them in the memory clinic and they’re doing much worse than other people their age and it’s enough to affect their function.

But it’s not a clear cutoff, and this is why people use some online tests that you can do that rate your memory or they go to their doctors to get screening tests for their memory. But I think that the clear cutoff is if it’s affecting your function. And you can think of examples when patients say, “Okay, what’s normal? What’s not normal?” If you meet someone on the street you haven’t seen for a year and you can’t remember their name, that falls in the normal range. If you go to a family gathering and see a close relative you saw a week ago and can’t remember their name, that’s clearly abnormal. So, it’s shades. You can see where normal shades into abnormal, and that’s what we look for because abnormal is disease.

 Leanne Kaufman:

So when we’re talking about that disease and when we may have crossed over in the threshold of into the abnormal, what are some of the risk factors, whether they’re controllable or non-controllable, that we should be looking out for if we are starting to feel like maybe we were on the precipice or our loved one is on the precipice of crossing that threshold?

Dr. Howard Chertkow:

About a fifth of people in their 70s and 80s either have dementia or have significant mild memory loss, which is not normal. So glass half full people who say, “Well, four out of five people are fine,” but one out of five people are really in this abnormal range. When we look at those people, half of the risk of your brain aging, abnormal brain aging, so to speak, half of the risk is genetic. We now know about close to 85 genes that affect people’s thinking and memory as they get older. Some of these, very in the minority, are inherited, what we call autosomal dominant. That means if you inherit the gene from your parent, you will get dementia, and that’s called familial dementia, that’s very rare, but most of the other ones add a little bit to your risk, so it’s cumulative. Overall then, half of the risk is genetic, that means half is not, and there’s a growing list of things that are not genetic that can contribute to your risk.

The biggest category is what we call vascular disease. Anything that’s bad for your heart is going to be bad for your brain. We all know this list. The public health people have been telling us about how to prevent stroke, how to prevent heart disease, so treating high blood pressure, treating diabetes, not smoking, treating cholesterol, not being obese and, to a growing degree, we’re recognizing that overuse of alcohol is on this list as well. So these are the vascular risks and this is why I’m going to come back to the most important thing you can do is to control these vascular risks and do exercise.

The other risk factors, and there are many, some of them are expected and some are unexpected: people who have a bad sleep. If you sleep less than five hours a night, you’re increasing your risk of getting dementia. We didn’t know this 20 years ago, but when you are asleep, your flow to your brain cells changes and you clear out toxins in the brain, and part of getting dementia is accumulating dangerous toxins in the brain, proteins and other chemicals that are damaging the brain cells. So you have to sleep. This is pretty easy to change, it is probably the easiest lifestyle factor that you can change. So if you’ve been sleeping less than five hours, even less than six hours a night, add an hour of sleep. It’s tremendously good for you, and I can’t reinforce this enough.

Brush your teeth and floss your teeth. What do teeth have to do with the brain? Well, again, 20 years ago the answer was nothing. Now as we’re beginning to understand the microbiome, the bacteria that live in your mouth and in your stomach and in your intestine. We know there are some bacteria in the gums that release toxins that go to the brain. People who floss, it lowers your risk of getting dementia versus people who don’t floss, and we think it is by controlling the population of bacteria. So brush, floss—things your mother told you to do, they were correct.

We get into toxins, I talked about toxins that get into your brain and we know that toxins come from alcohol, alcohol is a toxic to the brain. So overuse of alcohol. How much alcohol is too much? This is an area of debate because when you drink a little bit of red wine, it gives you antioxidants. There was actually one study at least that showed that people who drink one glass of wine or half a glass of wine a day actually gives you some protection with antioxidants. But most people who drink more than that, it is going to be toxic to the brain and damaging in the long run.

Now, if you say to me, “What about cannabis?” There, the jury is still out. There’s certainly a lot of work that cannabis in the short term will affect your memory. In Toronto, Nathan Herrmann, a doctor at Sunnybrook did good studies with Krista Lanctôt, a scientist—they’re showing that if you take people who smoke cannabis every day and get them to stop, their memory improves within a matter of a few weeks. So the problem is, like most lifestyle things, is getting them to stop.

Now we turn to things which are little less easy to pin down, but stress. We know stress affects the brain. People who’ve had post-traumatic stress disorder, you can look at brain scans and the hippocampus, the critical memory structure is smaller and people who’ve been under tremendous stress. How much stress is too much? This is what’s hard to evaluate because one person’s stress is another person’s happy lifestyle. So stress, if you’re under too much stress and you’re the only one who can assess this, it’s bad for your brain.

But other things are factors in the long term. People who are lonely, people who have less of a social network, men who are unmarried in middle age, all those things increase your chance of getting dementia. Why? We don’t know. I mean, we know men who live without a wife don’t look after themselves as well and their diet, their vascular, their alcohol, they’re all in the bad direction. But why do friends help prevent dementia? Not only friends, but they’ve done surveys that show people have less of a sense of meaning in their life as they get into their 50s and 60s, they’re at higher risk of getting dementia. So there are social elements, these are reasons we don’t really understand, having a good social life, connections, a network, a family, they are helping to preserve your brain as you get older.

I’ll add one more to the list, it’s a long list, and it’s a growing list. The last two things are diet, because certainly there seem to be things we can do in diet that help protect the brain and things that we’re doing in diet that are bad for the brain. The last two are education, more education, being bilingual or trilingual or getting stimulating brain activities protects your brain. Sitting on the couch, being a couch potato has the opposite effect. Probably, pollution. If you live in a highly polluted area—now we’re getting increasing evidence that you have a higher risk of getting dementia—how polluted it has to be, this is what’s unclear, but in Mexico City, which is a highly polluted city, we’re seeing changes of Alzheimer’s disease in the brains of people in their 20s and 30s. so I think pollution is a really important factor.

 Leanne Kaufman:

I am doing my own little mental checklist of the things that I can control and the things that I can’t control. I argue that the sleep one is one I would like to achieve, but I sometimes feel I can’t control that one. There’s probably some myths or some misconceptions about prevention or causes. Is there anything that you know from your research and experience that either previously was thought to be either a prevention or a cause and now that’s been proven to be untrue?

Dr. Howard Chertkow:

Well, there’s a lot of things that are under debate. Now there were years before where we thought aluminum, maybe aluminum antiperspirants or aluminum pots might cause Alzheimer’s disease. This has become less and less likely. Although there’s still some people who believe that your exposure to metals may make a difference and it’s complicated. The genetic determinism. Some people say, “Look, my mother had Alzheimer’s, I look like my mother, I’m going to get it.” That’s not the way genes work. Having a positive family history, that means your mother had Alzheimer’s disease, that doubles your risk against the rest of the population. So remember I talked about one person out of five getting dementia or mild memory loss, your risk is double if your mother had it, but that’s not a hundred percent. There still leaves a lot of room for things that can be done. We believe if people modify their lifestyle, maybe 40 percent of dementia cases could be prevented. So there’s a lot that people can do.

 Leanne Kaufman:

Wow. So picking up on that then, if you had to pick sort of the top three things that are the most easily modified—moving your house away from an area of deep pollution may not be an easy one—but just give us three things that someone could start doing tomorrow to help protect their future self.

Dr. Howard Chertkow:

Well, exercise is the top of the list. In every study exercise comes out as the most robust modifiable risk factor. How much exercise? Well, the recommendations for [your] heart are 150 minutes a week of moderate exercise. That means exercise where you’re working up a sweat. So that should be an attainable goal for virtually everyone in the population. Exercise is magic. In studies, it basically takes five years off your brain age, it reduces toxins, increases blood flow, it works over and over again.

What is number two and three? This is the question, and to be honest, we’re not quite sure what is the top-hit-list for the other factors. Because really, although we know from population studies of the relationship of these factors, no one has done the proper controlled trials. They’re very hard to do. At Baycrest we’ve started a new centre, the Kimel Centre, where we’re going to actually try to do proper research on how much of an impact you get if you change your diet, if you change your sleep, if you start flossing. How much do these actually reduce your risk? This is an important question.

So once we get beyond exercise, it’s also personalized. For some people, they can’t change anything because they’re already doing the right thing. I think rather than saying overall, “What’s the top three list?” Every person has to look at this list and say, “For me, what are the three things I can be changing?” One I haven’t talked about is diet. There is pretty good evidence that the things like the Mediterranean diet and the MIND diet, which are simply good for the brain. These are diets with less red meat, more green vegetables, pasta, fruit—especially fruit like oranges, which have a lot of antioxidants—cold water fish like salmon, and moderation, getting rid of obesity and having more protein, less sugar, less red meat. These diets are, for multiple reasons, beneficial for the brain. The other thing is including flavonoids. These are chemicals that are in berries, very colorful berries like raspberries, strawberries or dark chocolate, all those things have flavonoids. And there’s a good study, again, mainly in animals, that this is going to preserve your brain from aging and getting dementia.

 Leanne Kaufman:

I’m always going to be happy if you tell me one glass of wine and some dark chocolate is going to help me with my health, that’s always good news. I mean, there’s so far we could go into all of these risk factors and get deep into the weeds on this, but we really are just trying to kind of touch the surface on the topic in today’s conversation. So if you could hope that listeners would just remember one thing from what we’ve talked about today, what would that one thing be?

Dr. Howard Chertkow:

Well, maybe the best is to… also, I’ll change that to two things. I think you have to start thinking of your brain as the quarterback on a football team. You’ve got to increase the things that defend your brain, you’ve got a line of defenders and you’ve got to decrease the attackers on your brain. So it’s a combination of multiple things that everyone can do. I think that we talk about walking book clubs, that’s the ideal, a book club. What are you getting in a book club? You’re getting intellectual stimulation. If you’re walking, you’re getting exercise, if you’re in a club, you’re getting social engagement. So those are the three areas that we could all be working on improving in our lives.

And protecting your brain the way you protect your heart. At this point, there’s so much evidence about smoking that I guess people realize that they’re doing something bad for their heart by smoking, but it’s bad for your brain as well.

I think that what people have to think about is the one area that I haven’t talked about, which is motivation for change. This is another area as scientists we’re trying to learn more about. Changing your lifestyle is not easy. And what’s the trick, what’s the phrase that will get people to change their lifestyle? How do people get motivated to make these changes they know they should change? And this is a bit of a mystery area. Psychologists are turning to it, and it’s maybe not one size fits all, but certainly finding your own motivation for change is a critical part of the process, because everyone can write down this list on a piece of paper of things they should change, and everyone makes New Year’s resolutions—we know that New Year’s resolutions usually last about a month. So this is the key thing, people have to try and figure out for themselves what it will take to motivate them to change their life.

 Leanne Kaufman:

That’s a great way to end it. You know you struck another chord with me, so now I’m happy about the dark chocolate, I’m happy about the glass wine and I’m happy about the book club. I will suggest that my book club girls—shout out to my book club girls—start walking, but it might make it harder to drink the wine, so we’ll have to decide which one we want to go with there. So thank you so much Dr. Chertkow for joining me today to talk about dementia, its prevention and tactics we can all use and why this all matters beyond wealth.

Dr. Howard Chertkow:

Delighted to be here with you.

 Leanne Kaufman:

You can find out more about Dr. Chertkow at Baycrest.org. If you enjoyed this episode and you’d like to help support the podcast, please share it with others, post about it on social media, or leave a rating and review. Until next time, I’m Leanne Kaufman. Thank you for joining us.

Outro speaker:

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