How does our memory work?
Dr. Schulz: The first step in remembering something that I am hearing. For example, what you are saying is that I have to focus on you and on what you are saying and that takes a fair bit of brain power that comes from the front, right behind the forehead. That is my attention area. That area then takes the information and sends it to where it is going to be stored longer term. And by longer term, I mean from a few seconds to a few days, and then finally it is stored in another place long term. As you can imagine, if I have a hard time focusing on you, then information does not even get to where it is supposed to be stored, and therefore, I will not remember it later on if you ask me about it. When I am watching a football game or some gentleman is watching a football game and his wife says something to him, if he is not really paying 100% attention, he really won’t capture everything that she is saying to him.
How about brain power? How does that work?
Dr. Schulz: We know from testing that people’s attention and learning improves up to about the age of 20, and then around that period of time people are sort of at their peak. Beyond that, the attention span starts to go down, and because of that learning goes down by about the same amount. Now, of course, attention can have a bigger or lesser effect on memory on a given day, but in general, memory would decline also about 40% based on the fact that attention span has changed that much. I see people every day of the week who comes in and they notice that their memory is not what it used to be. They meet people at a social event and they cannot remember their names. They forget their keys. They are forgetting daily events. Sometimes, they will say ‘someone told me about a conversation we had and I did not remember the conversation at all’. They are very worried because they have learned about Alzheimer’s disease or they have had a relative with Alzheimer’s disease, and they want to know if they have it. If I test them and they end up being, at 80 years old, if they have the same 40% change that everybody their age has, I can give them the reassurance that they are okay for age. You could argue that being normal for 80, it is a 40% change and frankly, most smart people notice that they are not the way they were when they were 20. It reminds me a lot of sports. I run with younger gentleman and no matter how hard I try at my age, I cannot run as fast as them. In Olympics, everybody who is really high performing is in their 20s and early 30s. It is the same with brain power. It is very similar to our sports prowess in that there is sort of a peak period of time there when we are at our best. And then, it is not as good after that.
Why is that?
Dr. Schulz: It is not 100% clear. With sports, by the way, it could be wear and tear, but it could also be that there are certain growth factors, for example, that are necessary when you are training hard to build up muscle and endurance and all the oxygen carrying capacity and so forth. Those genes may be turning off as you get older. That may account for why there are sports related changes. We do not know for sure why those areas of the brain change. We do know that if we do serial imaging on people. Meaning, I take an MRI at age 20, and 30, and 40, we will see a change in the size of the brain normally. There must be a certain amount of cell loss that is normal, and our thought is that it is probably a big part of it. It is so consistent across people that it is hard to imagine it is a single event. There are a lot of events that enhance that. We know that if people get bumped on the head once or more than once, especially since the attention area is right under the forehead, which causes potentially a very large change in people’s attention span. Getting knocked out even for a few minutes, would be a prime example of that. There are a lot of other things on a day to day basis too. You mentioned flying in from another city. If people are tired, their attention span goes down 20%, 40%, 60%. When my residents are post call, sometimes they have a hard time remembering their name, much less anything else that went on. Of course, nowadays, we have changed the training of residents, so that they are not endangering the patient’s life, but the truth is when anybody gets tired or fatigued, their attention span goes down. In the afternoon around 4:00, 5:00, 6-o’clock, most people get fatigued and it is not by accident that is when most professions stop for the day or rest or eat dinner. I think normal people notice that at that time of the day, they really have a hard time focusing in meetings and so forth. They need to take a long break before they can really get back into things.
Does traumatic brain injury make your brain shrink?
Dr. Schulz: It shrinks and it has a real effect on people’s attention, therefore their memory and other functions. The attention area also does other things for you. When I go to find a word that I want to use in the conversation with you, I have to think of what I want to say and then I have to go to the dictionary in my left temporal lobe and look for the right word. If my attention span is not as good, most people notice that they have more and more times where they cannot think of the word they want to use in conversation. They might forget where their keys are. They might forget an event, but they may also have a hard time looking for certain common words that they are used to using as well.
What can people do to reverse it?
Dr. Schulz: There is a whole bunch of things that we have discovered are helpful for attention and memory as we get older. One is: it turns out that practice actually does help. I mentioned for example that my sister who is 50 years old is taking classes now. By the time she has finished several courses, her attention span will be better because she is now practicing that skill on a daily basis. Even people with dementia we have discovered, can improve certain areas of cognitive function through exercising them. They can improve their memory. They can improve their attention span if they focus on that and try it out on a daily basis.
What are some of the things you recommend?
Dr Schulz: When I see patients, I try to ask them anything that they think is fun to do because then they will be motivated to do it more highly. For example, if they are addicted to Sudoku, then I say that is a great way to increase your attention span and focus on focus, so to speak. As you know, it is a very difficult task to do. Other people like doing the New York Times crossword puzzle. Other people say to me, ‘I am really not a puzzle person at all, what can I do?’ and it turns out that even focusing on a complicated TV show or a movie and then talking about it, is a way of improving your attention span as well. If you go to a movie and it has a lot of twists to the plots, you really have to attend to it carefully to figure out what is going on. Conversely, if you then talk about what you saw there and you are practicing that on a daily basis, you can improve your attention as well. It could also be reading magazines. It could be reading books, especially if they converse about it. If a person just reads it and sets it aside and no one is testing them on it, then perhaps it is not as useful because they may not remember it, but no one challenges them on that. But particularly if a loved one is reading the same newspaper every morning, they can talk about that and ask about the headlines and what they learned from the article. There is also a lot of ways of taking advantage of the current attention span and making it better. Examples would be; I tell loved ones, when you go to talk to your spouse, number one, get their attention. They already have a not very good attention span. The first thing you want to do is say "George," and have them look at you and then you know you have their full attention. You also want to try to reduce distractors in the room. Not have the TV on when you are trying to talk to your loved one. Anything else that is making noise or potentially is distracting, you want to remove that. Then, say their name so they are looking at you and then say what you want to say to them and ask them to say it back to you. At a minimum, they have then heard the conversation twice. They have heard you say it and they have heard themselves say it back to you. You can also wait another minute and ask again. "Now, George, what were you going to get at the grocery store today?" And see if they can give it back to you. If they cannot, then you can repeat it a third time and have them repeat it back. There is a whole bunch of ways of reducing distraction and increasing the attention the person has. Even for those of us that have the normal reduction in attention, people find that if they repeat things, they are a lot more likely to remember it.
Can you tell me about the key test?
Dr. Schulz: One of the third things that we can do is sort of a crutch I would call it, which is when you know your attention span is not as good as it used to be. It is probably not a good idea to put your keys in a different spot every time. Every time you put them in a different spot, you have to remember where you put them. For that kind of circumstance, I recommend that people have a very regular location where they put their keys, a certain part of the house, where they always put their wallet, they always put their umbrella. There is another attention enhancing method that all of us use intuitively, but you might not think of it that way, and that is caffeine and products like that. This morning I came to work and I did not have any coffee before I started seeing my first patient, and I was aware of the fact. I had to really focus very hard on what they were saying to capture everything they were saying, whereas normally if I have had a coffee or 2 or a Coke product, that has caffeine in it, my attention span is already a lot better when I get started. People use that on a regular basis to help enhance their attention span and it works for everybody regardless of age.
Are there different foods that can help your memory?
Dr. Schulz: For plain nutrition, it has been hard to show a single regular product, like a certain vegetable that helps your thinking, but what we do know is that especially for folks who are at risk for further cognitive impairment, all of the so called vascular risk factors are risk factors for dementia. This is a little bit opposite of what you are asking. But, for example, we do know that keeping your lipids down, your blood sugar down, your cholesterol down, your blood pressure down, makes a huge difference in terms of your risk of having worse cognition as you get older. If people have a large waist size, if their triglycerides are elevated, if their blood sugar is elevated, if their cholesterol is elevated, if they smoke; all of those things individually have about a doubling of the risk of getting cognitive impairment later on, which is what we call dementia. We used to think that the only way that smoking was a risk factor for dementia, was through producing strokes. It does increase the risk of vascular dementia, which is stroke-related dementia, about fourfold, but it also increases the risk of Alzheimer’s disease about two and a half fold. We now recommend for everybody that smoking is bad even if you do not have other stroke risk factors, because for Alzheimer’s alone it is a risk factor. The same with waist size at middle aged. I hate to say that for all of us that are middle aged. If we measure waist at middle age, we can also get a sense of or predict the risk of dementia 20 years after that.
What waist line do you want to avoid?
Dr. Schulz: The normal BMI, the basal metabolic index, which is a ratio of height to waist size, is about 25. If we see 26, 28, 30, we start to get very worried. Twenty-five to 30 is considered to be overweight and over 30 is considered to be obese. As you may know, 30% to 40% of Americans do fall into that category of being overweight or obese, and both of those are independent risk factors for dementia on top of everything else like age and gender and other medical illnesses that people have. If you are a healthy person and you want to keep your mind healthy, then what I do when I see a person like that is I go through all the risk factors for cognitive impairment and try to get all of them under control. Let’s stop smoking. Let’s reduce our weight and get it in normal range. Let’s check your blood sugar and if it is elevated bring that down. Let’s check your cholesterol and triglycerides and if those are elevated, bring those down.
Are people surprised when you tell them that these things are linked?
Dr. Schulz: Very much so. Part of it is we have only discovered it in the last couple of years. I do not think it has really gotten out there yet that these are all risk factors for even Alzheimer’s disease, not just strokes and heart attacks. This is what everybody has been worried about since the 1960’s when we discovered that elevated lipids were bad for heart attacks and strokes.
How can supplements help you boost your brain power?
Dr. Schulz: Some of them may work. We just do not have strong evidence that any of them produce a direct effect. Other than caffeine which increases alertness and attention, it has been hard to show that certain vitamins at elevated levels are useful. Now, on a daily basis, I see people who have deficiencies of vitamins. For example, B12 deficiency produces cognitive impairment. In that case, I give people supplements. A deficiency of vitamins is certainly a risk factor for cognitive impairment. It has been hard to show that taking extra is necessarily valuable at this time. It does not mean that we shouldn’t do it, or that it is not helpful, but it means that it has been hard to show that definitively.
Which one is more popular?
Dr. Schulz: There is a whole host of vitamins and minerals that people tell me about. Probably, ginkgo biloba would be a common example. Ginkgo, actually has quite a bit of caffeine in it and I think that just like having a caffeinated beverage, it probably does help people’s attention and focus. When folks take Selenium and other products like that, I am not so sure that they are valuable in that regard. It is just that we have not shown that they are useful.
What exercises can we do to improve our memories?
Dr. Schulz: That is a very good question. If I asked you whether you thought that physical exercise or mental exercise would be better for your thinking, my guess is that you would guess that mental exercise. It seems like a very direct. You do the mental exercises, it ought to help. It turns out that mental exercises are very helpful for the specific thing that you exercise. For example, if you exercise attention, we can show that that will improve, but it may not have an effect on language and other functions. One of the fascinating things that have been discovered and been repeatedly replicated, is that physical exercise actually helps cognitive function across the board, and this is true for our patient’s with dementia as well who have impaired cognition. Twenty to 30 minutes, 4 times a week of aerobic exercise has a very easily effect on cognitive function. You can see a change in the number of synapses. There are more of them in people who exercise regularly. There are also of course the two other added benefits of exercise. One is that exercise has been shown repeatedly to be a great elevator of mood. It is an antidepressant if you will. Then in a positive direction, people often talk about having a sort of mild buzz if you will, or a runner’s high or whatever different professions call it. Even my wife, who does yoga, says that she gets a certain buzz out of that and I am sure they are all related to each other. There is a positive feeling that comes from exercise. The third benefit is that it also lowers your blood pressure and lowers your lipids and so forth. It lowers your vascular risk factors and your dementia risk factors, so there are three ways at least that we know of that exercise is beneficial now.
How about brain exercise websites?
Dr. Schulz: I think that exercising your attention span certainly improves it and there are a lot of ways to do that. We mentioned some of them already. I think Lumosity and other sites offer other sort of ways of approaching that, and for some people I think it is convenient to sit down at their computer, and for them, having a program that they can do online is probably very helpful. Not everybody is motivated to do Sudoku and crossword puzzles for example. I think for different people, different forms may be better. I do not know that we have any evidence that one form is better than another. I think, in fact in the opposite direction, it seems as though exercise of any sort is very helpful and the specific type that you choose just depends on your own level of interest and motivation for that particular form.
How about games?
Dr. Schulz: That is actually a very good point also. I think the games on the phones for a lot of people certainly seem to involve a lot of focus and concentration and learning of a task. I would imagine that they would also be helpful.
What is mild cognitive impairment?
Dr. Schulz: Mild cognitive impairment means that a person has a problem with memory that goes beyond normal for age. When we say mild cognitive impairment, we mean just one area of cognitive impairment and it is usually memory. Let’s say someone has amnestic mild cognitive impairment, meaning they have memory problems and nothing else. Their memory problem is greater than the amount that we see normally for age. For example, at age 60, I mentioned that someone might have a 25% reduction in memory. When I see someone who has a 50% or an 80% reduction, we call that mild cognitive impairment. The reason that we get very, very excited about mild cognitive impairment nowadays is we recognize that it is a very large risk factor for dementia. We now know that about 80% of people with mild cognitive impairment will develop dementia over the next 5 years. It is an opportunity to intervene in someone that is at high risk for developing dementia and it is an opportunity to try to help them and prevent them from going onto dementia. Many of us are studying people with MCI in order to try to develop preventions for progression to dementia. The study about nicotine was one example of giving people with MCI a substance that was tested for its effect on attention and memory span. In fact, they found over a 6 month period that people with MCI had better attention spans and did better on testing for attention than the folks who were on the placebo. The disappointing part was that it did not cause a change in what we call the global impression of change. What investigators and the FDA have decided is that there are many things that could potentially cause a small impact on people’s memory and attention, but before we will allow companies to advertise their product as being useful for that, it has to actually have a real world beneficial effect. That was where the nicotine study did not quite pass the muster, in that is that the clinicians and the family members did not notice a big change in their memory, but when we tested it, it was better. I think it sort of goes in the category of caffeine where we all know that we are a little better when we are on that, but I am not sure that I can identify whether you are on caffeine or not on a certain day. It is that kind of a thing. It is working on the cholinergic system which is involved in Alzheimer’s disease, and our hope would be that if they do a longer term study and with a larger number of patients, perhaps there would be benefit. The bottom line from the study is that we need another study that is larger to investigate that. At this time, we cannot advocate it as a preventative mechanism or something that affects the course of the illness for example.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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