February 6th,2016

The Aging Brain

Jonathan Artz, MD-Union College NY (BS- Biological Sciences, PBK,MCL).

-Emory University School of Medicine- Class of 1993

-UNC- Chapel Hill- Internal Medicine and Neurology

-University of Virginia- Fellowship (Neurophysiology/Epilepsy)

-University of Pittsburgh (UPMC-Presbyterian)- FellowshipNeurophysiology/Neuromuscular Disorders.

- Kaiser San Rafael- Staff Adult Neurologist since 2001

The Aging Brain- Objectives 1. Learn about basic adult brain anatomy and

Neurophysiology.2. Understand the differences between normal

brain aging, mild cognitive impairment and neurodegenerative dementia.

3. Understand the major factors that can affect a person’s memory and cognition.

4. Recognize clinical factors that could require additional medical or neurological investigations.

5. Realize how you can main good brain health.6. Have fun, get educated and not fall asleep !

Disclosers

1. All knowledge is from my own clinical experience,education,review of the literature (ie, Academy of Neurology), Wilkepedia, CDC/NIH documents and selected information from googling.

2. I have no financial relationships with any pharmaceutical,nutriceutical, software or technology company or other for- profit ventures.

Housekeeping Rules1. No I-phones,smart phones or other audio-visual recording devices allowed during presentation.2. Pagers and other communication devices should be adjusted to vibrate mode.3. Bathrooms (upstairs and downstairs)- use beforehand or sit in the back of room.4. Lecture: 1 hour and 45 minutes followed by 15 minutes (or so) for questions.5. Save questions for end please.

The Brain’s Vital Statistics

ADULT WEIGHT about 3 pounds ADULT SIZE a medium cauliflower NUMBER OF NEURONS around 100,000,000,000 (100 billion) NUMBER OF SYNAPSES (the gaps between neurons) about 100,000,000,000,000 (100 trillion)

The general recollection network. The figure illustrates the outcome of the contrast between accurately recognized test words endorsed as‘Remember’ or ‘Know’ in an unpublished study (n = 19) of Wang and Rugg. The words had been studied either as pictures or as words in the context oftwo different encoding tasks. Regions are shown where recollection was

associated with enhanced activity at test regardless of the encoding condition. Vilberg and Rugg. Current Opinions in Neurobiology, 2012, 23: 1-6.

The Brain Shrinks over time !

Based on MRI images-

Most tissue loss and changes seen in the:

The Frontal and Temporal lobes.

Neuroscientist Jeffrey Kaye of the Oregon Health and Science University used MRI scans (like those below)

to track this process

Short Term Memory

1. Storing information temporarily and determining if it will be dismissed or moved to Long Term memory.

2. “Working” memory- the brain’s scratch pad that keeps information (a number, a name) on hand long enough to use it.

Long Term Memory• Characteristics of this type of Memory:

1.Anything you remember over a few minutes ago.

2.These memories are not of equal strength.3. They are subject to change (ie, practice

and repetition can increase synaptic connections and can improve this type of memory).

Types of Long Term Memory

Explicit Memory

1.Requires conscious thought2.Associative- Your brain links memories together.Examples:A. Recalling who came to dinner last night.B. Recalling what animals live in a Rain Forest.

Episodic Memory Autobiographical Information

1.Times2.Places3. Associated Emotions.4. Who,What,When,Where Why Information5. Collection of past personal experiences that occurred at a particular time and place.

Semantic Long Term Memory 1. Textbook learning 2. General knowledge about the world acquired over our lives. Examples:A.Enables us to say, without knowing when and where we learned, that a zebra is a striped animal or that Sacramento is the capital of California.B. It is better sustained over time (unlike episodic memory)

Semantic vs Episodic Memory

Procedural Memory Procedural learning

1. Repeating (practicing) a complex activity over and over again until all of the relevant neural systems work together to automatically produce the activity.

2. Is essential for the development of any motor skill or cognitive activity.

Procedural Memory and Anatomy

1. Basal Ganglia-Linked to formation of motor behaviors and habits.

2. Cerebellum- Plays a role in correcting movement and in fine-tuning the motor agility found in procedural skills such as painting, instrument playing and in sports such as tennis.

Amygdala- Emotion and Memory

Amygdala

1. Involved in figuring out the emotional significance of events and is responsible for the influence of emotion on perception of an experience.

2. This set of brain cells helps alert us to notice emotionally significant events even when we're not paying attention.

Examples: ?

Memory Lapses

• People commonly associate memory lapses in their mid-30s, 40s, or 50s as a sign of Alzheimer’s disease as they approach later adulthood, but typically this is not the case. Memory lapses can be both aggravating and frustrating but they are due to the overwhelming amount of information that is being taken in by the brain

Normal Age Related Effects in Memory

1. Occasionally forgetting where you left things you use regularly (keys,wallet,glasses).

2. Forgetting names of acquaintances or infrequently forgetting an appointment (date/time).

3. Having trouble remembering what you just read or the details of a conversation.

4. Walking into a room and forgetting why you entered.

5. Suboptimal retrieval of information “on the tip of your tongue.”

Age and Short Term Memory

1. With aging, the amount of time our short term memory can store information becomes shorter and shorter. 2. With aging, there is time to move new information to long term memory> making it more likely to forget recent events. 3. Memory lapses are a normal part of aging to a degree !

The Aging Brain and Cognition

As we age, difficulties are seen in the ability to integrate, manipulate, and reorganize the contents of working memory in order to complete higher level cognitive tasks such as:

Problem solving Decision making Goal setting Planning

Normal Aging and Memory

1. Episodic Memory is especially impaired in “normal” aging.

2. More difficulty encoding new memories for events or facts.

3. Source Information (where and when one learned the information) declines with age.

4. Degradation of white matter tracts linking frontal-temporal-parietal lobes.

5. Hippocampus starts to shrink at age 30.

Age Associated Memory Changes

1. Able to recall and describe incidents of forgetfulness.

2. Able to function independently and pursue normal activities, despite occasional memory lapses.

3. May pause to remember directions, but does not get lost in familiar places.

4. No trouble holding or understanding a conversation despite the occasional difficulty finding the right word(s).

Types of Memory Spared in Aging

• Procedure Memory- minimal to no decline with age.

• Semantic Knowledge (memory)- stable or improves with age.

Mild Cognitive Impairment

Short term Memory and/or Cognition that does not significantly impact daily functioning.

Mild Cognitive Impairment

The diagnosis of Mild Cognitive Impairment relies on the fact that the individual is able to perform all their usual activities successfully, without more assistance from others than they previously needed.

Mild Cognitive Impairment

Memory or cognitive complaints:1. Trouble remembering names of people one met recently.2. Trouble remembering the flow of conversation and an increased tendency to misplace things.3. Person will often be aware of these issues and will compensate (ie, note taking and extra reliance on calendar use).

Mild Cognitive Impairment

1. There are no FDA approved treatments (ginko,vitamins,Aricept,Exelon,galantamine or Namenda).2. The main goal is to identify risk factors (High blood pressure, medications, excessive alcohol use, poor sleep/insomnia, mood related issues) and improve on them.3. Physical Exercise is useful tool to better control several of the risk factors above.

M.C.I. >> Dementia Suspect an Early Stage of Dementia (most common form being Alzheimer’s Type) if :

1.There is confirmation of significant memory difficulties by a knowledgeable informant (family member, close friend).2. Any change in ability to perform daily tasks such as hobbies,finances, or attending to ones personal hygiene.3. Poor performance on objective memory Testing.

Dementia1. Alzheimer’s Type (75% of all Dementias).2. Vascular related (Stroke)3. Alcoholism or other drug/toxin related.4. Result of Head injury/Concussion.5. Depression (“Pseudo” Dementia)6. Prolonged Sleep Deprivation7. Medication effects (anticholinergic drugs

and some sedatives).8. Result of prolonged oxygen deprivation

despite Cardiac Resusitation (CPR).

When you should call your Doctor

1. Any progressive decline in short term memory and/or cognitive functioning that is affecting your daily functioning.

A. You are unable to recall circumstances where memory loss caused problems.

B. You are getting lost or disoriented in familiar places.C. You are unable to follow directions or multi-task

(cooking,cleaning,driving, during hobbies).D. Your words are frequently forgotten or misused;

repeating phrases or stories in same conversation.

Identify Your Risk Factors

Functional Activities QuestionairePfeffer, RI (J Gerontology, 1982)

1. Writing checks and maintaining other financial records.

2. Asembling tax or business records.3. Shopping alone.4. Playing a game of skill.5. Making coffee or tea6. Preparing a balanced meal.7. Keeping track of current events.

Functional Activities Questionnaire8. Attending to and understanding a television program, book or magazine.9. Remembering appointments,family occasions and medications.10. Traveling outside of neighborhood.Score (0-3 for each above item):a.0- independent.b.1- mild difficulty c.2- requires assistanced.3- dependent

SCORE of > 8 equals functional impairment

Towards a Healthier Brain

1. Nutrition-Diet: low fat and sugar content2. Weight : (linked with Diabetes risk) -Goal BMI under 25 (normal 18-25).3. Sleep Hygiene4. Stress and Anxiety reduction (meditation).5. Social Interactiveness6. Mental Stimulation7. Daily Aerobic forms of Exercise 8. Avoid smoking,excessive alcohol use

Brain Derived Neurotrophic Factor (BDNF)

1. Found in Hippocampus and Frontal Lobe (Pre Frontal Cortex) - areas vital to learning, memory and higher level thinking.

2. Parts of the adult brain retain the ability to grow new neurons from neural stem cells in a process called NEUROGENESIS.

Neurobiological Effects of Physical Exercise

Aerobic exercise- (30 minutes a day) induces persistent beneficial behavioral and neural plasticity as well as alternations of gene expression in the brain.A.Increased Neuron growth.B. Improved declarative and working memory.C. Structural and functional improvements in brain structures associated with cognitive control and memory.

Aerobic Exercise

1. Running/Jogging.2. Brisk walking.3. Swimming 4. Cycling.5. Rowing.6. Skiing (especially cross country skiing)7. Tennis

Structural Growth Effects of Exercise on Brain MRI

Neuroimaging studies shows that consistent aerobic exercise increased gray matter volume in several brain regions associated with memory,cognitive and motor control.A.Prefrontal Cortex- required for cognitive control of behavior, working memory,attentional control, and cognitive flexibility.

B.Hippocampus- declarative and spatial memory.C.Cerebellum- motor coordination and motor learning.

Healthy Sleep Habits1. Avoid caffeine, alcohol, nicotine and other chemicals

affect sleep.2. Turn your bedroom into a sleep inducing environment.3. Establish a soothing pre sleep routine.4. Do not read in bed or watch TV in bed (the bed is for

sleeping !).5. Keep a consistent sleep schedule.6. Balance fluid intake- liquids cause urination !7. Exercise early (not just before bedtime).8. Keep naps short before (5 pm)9. Finish dinner several hours before bedtime to avoid

indigestion.10. Try and get consistent 7-8 hours of sleep each night.

Brain Healthy Nutrition1. Diet low in processed sugars (under 30

grams a day).2. Fruits and Vegetables stressed every day.3. Daily calories of between 1800 to 2000unless lower amounts required for weight

loss or other medical need.4. Avoid trans fats (unhealthy fats).5. There is not a specific “Brain Diet”

known to work or be effective to improve brain functioning.

Kaiser Permanente Healthy Living1. kp.org/healthyliving/nca (classes and

podcats).

2. kp.org/mydoctor (to choose a doctor).

3. San Rafael Medical Center and Novato- Health Education Centers- 415-444-2173.

4. Petaluma Health Education Center- 707-765-3485.

KP Preventative Care App-(For I phone or Android compatible Smart phone)

Life Care Planning

• Who would speak for you if you were ever unable to communicate for yourself ?

• Choose your healthcare agent now and share with him or her what matters most to you when it comes to health care.

kp.org/lifecareplan