When Is Forgetfulness a Sign of Alzheimer's? with Dylan Wint, MD

Podcast Transcript

John Horton:

Hello and welcome to another Health Essentials Podcast. I'm John Horton, your host.

Truth be told, we all forget things from time to time. That's how you come home from the grocery store without that gallon of milk you needed.

Now, when you're younger, that's just a funny “aw-shucks” moment. But once you hit a certain age, forgetfulness can begin to cast a more sinister shadow. You start to wonder if you're losing it, and all of a sudden, you're Googling “Signs of Alzheimer's Disease.” Is that an overreaction? Maybe. But it's also a very real response and worry.

So today, we're going to talk with neuropsychiatrist Dylan Wint about memory loss and when forgetfulness becomes a concern. Dr. Wint is a specialist in degenerative brain diseases and one of the many experts at Cleveland Clinic who visit our weekly podcast at Talk Health. Now, let's see if we can unlock the mystery of mental lapses, or at least remember where we put the key.

Welcome back to the podcast, Dr. Wint. It has been far too long since you stopped by to chat.

Dr. Dylan Wint:

Well, thank you. It's a pleasure to be back.

John Horton:

Well, we're happy to have you.

Now, you're here to talk about Alzheimer's, and just the things that come with getting older. And as you age, there are a lot of worries, and one of the biggest involves the fear of losing your memory. I imagine that you see a lot of people wrestling with that reality.

Dr. Dylan Wint:

Absolutely. Dementia is now higher than heart disease, cancer and stroke as the most feared health condition in people over age 50. And what really worries me or troubles me is that somewhere on the order of 50% to 60% of people think that they will have cognitive decline as they get older. And about half of people think that their cognitive decline will become so severe that they'll become dependent on others, which is what we call dementia. Only about 15% to 20% of people think that they don't have to worry about getting Alzheimer's disease. And that's in contrast to the reality, which is that in individuals over age 65, about 15% of them will eventually get Alzheimer's disease or another dementia.

John Horton:

Well, I guess I like to be a positive guy, so that means 85% of people don't get it. So we'll try to put that positive spin on it.

Dr. Dylan Wint:

I think that's great.

John Horton:

Now, obviously, it is a big worry. And I think a lot of people, as you age, you start forgetting things, and it just seems like it happens more and more. Is this kind of increased forgetfulness a normal part of the aging process? I mean, do we just naturally start losing the ability to remember as much?

Dr. Dylan Wint:

That's a great question, and one that I do run into frequently. Our brains, without a doubt, do change as we get older, like the rest of our bodies change. And there are some cognitive functions that also change with age. We do tend to be slower cognitively as we get older. So it can take us a little bit longer to learn things, can take us a little bit longer to complete mental tasks. And multitasking, which in modern day is something that we're all doing all the time, that's really switching between two or more tasks very quickly. So as you can imagine, as cognition starts to slow down, it becomes harder to do that as quickly, and therefore, we may feel like we're losing some ability to multitask. These are all normal.

John Horton:

Yeah. And that's what fuels so much of the worry because you do have that maybe natural slowdown and you do start worrying if it's something a little bit more.

Dr. Dylan Wint:

And we have norms for all of these things. This is why it's so important that if you're worried to get cognitive testing — it can reassure you that what you're going through is normal. If you do find out that something is off, it may be something that's reversible, like a hormone or vitamin or electrolyte problem. And if you do have a degenerative condition, the earlier that intervention occurs, the better the outcome. So there's really no downside to looking into your concerns with a provider.

John Horton:

So let's talk about some of the signs of not remembering that maybe crosses a line. I know, as the gray hair kind of shows, I'm getting up there a little bit. I have now hit that point where I used to laugh at my grandparents and great-grandparents who used to run through five names before they hit mine. I'm doing the same thing, man. My grandkids were in this weekend, and I'd roll through my kids' names and then theirs before I got there. And you start going, "Oh man, is this the start?" So do I need to worry, Dr. Wint, or is that just kind of normal?

Dr. Dylan Wint:

Well, coming up with names is the number one problem that I hear people complain of who have completely normal memory as they get older. And that's a specific change that occurs. It is what we call “lexical retrieval.” So “lexicon” being like a dictionary. Lexical retrieval, pulling out that correct name from the long list of names that you have in your brain as you get older, becomes a slower process. But generally, we are aware that we're pulling the wrong name or that we're not coming up with the name. So one of the things that can signal abnormal cognitive change is when someone's unaware that they're coming up with the wrong name or they're using the wrong word, and they don't seem to know that they're doing that. Or if it's a regular, frequent occurrence that they cannot come up with a word and have to talk around it.

Rapid and complete forgetting of information — so “rapid” meaning within hours or sometimes even within minutes, and “complete” meaning that cues don't help — that can be a sign … that usually is a sign of an abnormal cognitive decline.

John Horton:

Yeah. So that would be something like if you just watch something, you're watching a game, and a play just happened, and like five minutes later, you totally forget about it. That would be something where maybe this is a sign of some slippage that may be just beyond just the normal aging part.

Dr. Dylan Wint:

That's right. That means the part of our brain that normally grabs and holds onto information, almost like Velcro®, as information is happening around us, our brain just naturally sort of captures it, particularly if it's important. That part of the brain may be failing, and that's the part of the brain that tends to fail most commonly in Alzheimer's disease. We can also see that show up as people repeating themselves, repeating a statement or a story or a question in fairly short order as if they never told the story or asked the question earlier.

John Horton:

Yeah. And I think that's a case where somebody in the same conversation, the story comes up again, not where you just, "My wife's heard my stories way too many times."

Dr. Dylan Wint:

You better get checked.

John Horton:

So it's more like when you have that same conversation. And I remember that with my grandfather. I mean, you'd have that discussion, and about a half hour in, he'd go right back to something that he told you 20 minutes earlier, and you're like, "Ooh, OK, yeah. I think I'm familiar with this.”

Dr. Dylan Wint:

Yeah, it's really that rapid forgetting. So you telling the same story with friends today and then telling them the same story, telling those friends or some of those friends the same story six months later, that's different. When we think about the forgetfulness that is abnormal, it's really forgetfulness that clearly occurs in a time period where everyone knows the person should have remembered that they gave that information.

John Horton:

What about losing things, because that's something we all do? I mean, the amount of times that you're looking for your keys or your phone or something like that, is that just a normal part or is there a time where that kind of crosses a line and it's maybe a little more concerning?

Dr. Dylan Wint:

So the frequency of losing things is one aspect that can be used to tell if it's not normal. So if someone is losing something like every day, that's not really normal. The inability to retrace one's steps, or once you find the object, to have no idea how it got there, that is abnormal. And then, finding objects, especially in very unusual places, places that don't make sense, and again, not being able to figure out how they got there. Or sometimes — we see this in folks who have memory loss — accusing others of moving the object. Those kinds of misplacing of objects may signal abnormal memory.

John Horton:

Yeah. That seems like the whole thing where you'll hear about people, you find something odd in the refrigerator and it's like, "How did this get here?"

Dr. Dylan Wint:

Yes. Yes.

John Horton:

What are some other things that maybe are signs that you've kind of taken a step past normal forgetfulness and maybe there's something more serious going on?

Dr. Dylan Wint:

So if you're seeing changes in personality or judgment, those are things that typically do not change normally as we get older. Our personality tends to be stable. Judgment actually tends to improve as we get older. So if you see impairments there, that's concerning.

Anything that interferes with your ability to perform your usual daily tasks. So some forgetfulness can occur, but if someone is forgetting to do things that are important on a daily basis, then that is not normal, by definition.

And then, the loss of abilities or skills, things that you know how to do and you're no longer able to do because of cognition. Like, I know how to spike a volleyball, but I cannot spike a volleyball anymore. I don't think that's my cognition; it's my knees. But anything that you've lost the ability to do because of a cognitive change, that should signal the need for an evaluation.

John Horton:

I take it that would be like if you've driven the same route over and over and over again, and then all of a sudden you can't find your way to the grocery store.

Dr. Dylan Wint:

Yep. Getting lost going to familiar destinations for sure, and even sometimes not being able to figure out how to get back on track after a detour or something like that. So sometimes, the first signal that families see is someone went to the airport, and there's always construction going to the airport, but they went to the airport, they couldn't get to where they were supposed to go for an hour or something. And their excuse is, "Well, there was construction, I got lost." And superficially, it sounds “Yeah, OK, that happens to me too, I get thrown off track when there's construction.” But to get lost for a long time because of a detour is abnormal. So either trouble finding your way to a familiar location or not being able to get to that familiar location if you get thrown off.

John Horton:

Yeah. You had mentioned poor judgment a little bit ago, and I feel like this is the sort of thing we always hear about or associate with scams and things like that. How big of a red flag is that, or is that kind of like a precursor to ooh, there's some bigger problems going on?

Dr. Dylan Wint:

Well, scams have become so sophisticated now that we can no longer say that, by definition, if someone falls prey to a scam that their cognition is declining. But it should lead to consideration for cognitive dysfunction.

So there's this one scam where someone calls you up pretending to be a close relative, that you need money, you're in jail or your car broke down or something like that. And that can be very tempting to send that money to your loved one who's in trouble and needs the money immediately. There may be people who fall prey to that whose cognition is normal. However, well, how come you didn't call anybody else? Or why did your grandchild, who's across the country, call you for this problem when they're an hour from their parents' house? So not going through some of those thought processes, not investigating, “Why are you calling me? What do you mean my grandkid's in jail, they've never been in any kind of trouble before?” The failure to ask those kinds of questions and to react on impulse to the emotional appeal may also signal that there needs to be some further investigation.

John Horton:

Yeah. It seems like there's just kind of an inability to make some of those thoughtful steps as you kind of process information and analyze it. There's just … some gaps kind of form.

Dr. Dylan Wint:

Yeah. There's a failure to come to the correct conclusion given the information in front of you, but also a failure to gather the information that you need prior to making that decision. And those two together can constitute a lack of judgment that indicates somebody's brain is not processing information the way that it should be.

John Horton:

One of the more interesting things I saw that could be kind of an early sign were vision or hearing issues. How does that kind of signal that maybe you've got some Alzheimer's starting?

Dr. Dylan Wint:

Well, sometimes, Alzheimer's can specifically affect visual pathways. So there's an atypical, unusual form of Alzheimer's where the brain's ability to process visual information is impaired. There can also be trouble with processing language that occurs because of Alzheimer's disease. However, if someone's brain is just sort of working harder in general to remember things, store information that's happening because of a decline in cognition, then they may have trouble when they need to use their brain's resources to process auditory or visual information. And sometimes, we interpret something like someone not remembering what you told them as them not hearing you, when what really happened is that they heard you, but they either couldn't process the information or they didn't recall the information.

John Horton:

Yeah. Now this whole list — and we've talked about difficulty doing daily tasks, trouble communicating, some little personality changes, losing things a lot, maybe some declining social skills — I think sometimes you see these things happen, but I think a lot of times, I don't know if you're afraid to make that leap to this signals something more, if it's with a loved one, or if you just wave it off as “Oh, it's aging and it's just grandpa being grandpa” or something like that. How hard is it for folks to take that step and connect everything together and go, "There's something more here."

Dr. Dylan Wint:

Well, first of all, I think it can be difficult to know if it's something more. It can be difficult for a neurologist who's been doing this for 20 years to identify what you hear as being normal aging versus something a bit more than that. So the first thing is that none of us really is in a great position to judge simply by observation or by hearing stories whether what's going on is normal. And so evaluation is important.

I think it may be also important for folks not to look at, well, is this dementia or is it not? But maybe think more about what are the potential contributions to this change I'm seeing in myself or in this person. Because often, there are multiple contributing factors, and sometimes a dementing disorder is not one of them.

And then, I think the third thing to remember is that the earlier the intervention, the more likely you are to have a good outcome. And that's regardless of whether what you're looking at is a neurodegenerative condition, like Alzheimer's disease, or an endocrine condition, like hypothyroidism, or an electrolyte imbalance, like low sodium. All of these, you're more likely to get a good outcome if you evaluate and intervene more rapidly.

John Horton:

OK, well, that's all good news because it sounds like there are other things then that can lead to these memory lapses.

So if you start seeing these troubling signs, I guess, what's the first step you should do to get things looked at?

Dr. Dylan Wint:

I think the first step is to talk to a primary care doctor. Primary care doctors are capable of performing cognitive screening tests. So these are brief tests that tell us whether what's going on in someone's brain likely requires further evaluation or likely does not. Screening tests are intended to capture as many people with cognitive impairment as possible, meaning that sometimes the screening test is going to be abnormal even though someone's overall cognition is normal. So the screening test just says, “Yeah, we ought to look into this further.” So that would be the first step to talk to the primary care doctor who knows your medical conditions, who has seen you before. Hopefully, you have a longitudinal relationship with a primary care doctor and may even have a baseline cognitive evaluation that they performed that they can compare to the screening tests that they do that day.

John Horton:

On that baseline note, is there a certain age where folks should just head in and get a test done, just so that way, you do set that baseline and know where you are at at a specific point in time?

Dr. Dylan Wint:

I think everyone should get a baseline cognitive screening. I would love for it to be by age 60, but certainly by age 65. There is a provision in Medicare's annual wellness visit. Cognitive evaluation is part of that visit. So if you are at your doctor or you're a senior and you're having your annual wellness visit, there should be a cognitive evaluation as a part of that. We don't necessarily want to get cognitive screening early if you're not having symptoms because it's not useful to compare, let's say, cognitive screening at 45 years old to cognitive screening that occurs at 65 years old. There are changes that occur that we expect with that. But I would say that probably from 60 to 65 years old onward, it's useful to have that baseline in your early or mid-60s.

John Horton:

All right. Well, it's good. I still have a few years then before I got to get in and have that. So I'm glad I'm not behind.

If you go in for this sort of screening or testing and they do see some signs of issues, can you slow down this sort of decline? I mean, are there things that can be done to keep it from advancing too quickly?

Dr. Dylan Wint:

Absolutely. So whether the screening test shows that you do have some cognitive decline or shows that you're normal, if you're concerned about your cognition, there are measures you can take to slow down cognitive decline. So very important among those are physical exercise. So we recommend 150 minutes per week on average of aerobic exercise. Diet can play an important role even in someone who has developed some cognitive dysfunction. So Mediterranean-type diets — I recommend the MIND diet specifically — can help to slow down decline. Keeping high levels of social activity and cognitive activity. So we know that social isolation can increase the risk of cognitive decline, and similarly, for mental stagnation. Getting proper amounts of sleep — so the right quantity, quality and timing of sleep. One of the best ways you can tell if you are getting those is how you feel during the day. If you wake up feeling refreshed and you're not sleepy during the day, your sleep is probably adequate. And then, taking care of medical conditions. So hypertension, diabetes, they're very large risk factors for cognitive decline. In addition, any changes in sensory input — so visual loss and hearing loss have also been identified as major contributors to cognitive decline.

John Horton:

You know, Dr. Wint, those sound suspiciously like the pillars of brain health that you talked about the last time you were on here, and I'm guessing that's not a coincidence.

Dr. Dylan Wint:

Not at all. So those pillars of brain health, we, for a while here, talked about six pillars of brain health. There's now a significant expansion in the number of modifiable risk factors for cognitive decline and dementia. Yeah, the six pillars are included in there, but there's the addition now of the sensory inputs, the social engagement and avoiding social isolation. There are other things that we don't have quite as much control over, such as environmental pollution that we have to address on a societal level.

John Horton:

It sounds like, from everything I'm hearing, though, it sounds like we need to pay attention to how our brain is working, how we're thinking things through and look for maybe some of these signs. And if you do start spotting them, take some action quickly because you can do things to keep as much of your brain functioning as what you really hope to.

Dr. Dylan Wint:

Yeah. Vigilant action is the key — not just paying attention and observing, but acting, doing something about it. Again, thinking what are the factors that may be contributing and which of those can I modify, which of those can I talk to my provider about modifying? And just like everything else in life, the sooner you get on it, the better the outcome will be.

John Horton:

Yeah. And Dr. Wint, you've shared a boatload of information here, probably more than I'm going to remember. But if folks are listening and if you want them to take one thing out of this, what do you want them to pull from this discussion?

Dr. Dylan Wint:

I think really that it's never too early and never too late to start considering your cognitive or brain health and doing things to make it better, not just now, but 10 years, 20 years, 30 years from now.

John Horton:

All right. Well, that sounds like a good place to start looking ahead, and I'm going to consider this a little bit of a cognitive test for me. Do I seem OK for the moment?

Dr. Dylan Wint:

Yeah, you seem to be doing pretty well, very well in fact.

John Horton:

Well, hopefully, that'll keep going, and I'll start my testing in a few years.

Dr. Dylan Wint:

All right.

John Horton:

So Dr. Wint, thank you again for coming in, and like I said, we really appreciate you just kind of lending your expertise to this and really kind of enlightening us on something that is, I know, a huge concern as we get older.

Dr. Dylan Wint:

It's my pleasure, John. Thank you.

John Horton:

A little forgetfulness is a normal part of aging, but if it starts going beyond the occasional misplaced key and begins affecting your everyday life, it may be time to take a closer look at what's happening and why. Getting answers early is the key to managing issues like Alzheimer's that may be affecting your memory.

John Horton:

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, be well.