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The Aging Brain: A caregiver’s guide

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Anshu Bahanda: Welcome to Wellness curated. This is your host, Anshu Bahanda, and in this episode, we’re going to discuss the aging brain and tips for caregivers. Now, my aim with this podcast is to help you lead a healthier, more hopeful and happier life. And we have today with us neuropsychiatrist and geriatric psychiatrist Dr. Santosh Bangar, who runs the MIND Clinic for senior citizens. We have senior political journalist, author, and TV talk show host Priya Sahgal, who looks after her aging mom and has authored a chapter in ‘A Portrait of Ageing’, a book edited by Zarina Bhatty. And we have Neurologist P N Renjen, who is from Indraprastha Apollo Hospital. Welcome to the chat. I will start with you, Priya. So, in your article in ‘A Portrait of Ageing’, you talked about how your mom has had falls and she lives with short term memory loss. Can you explain what that is?

Priya Sahgal: Thank you, Anshu, for having me on this, for this conversation. I think it’s a much needed one, really, because that’s something we are all going to face, either, when we are old or when we are still in our 50s but our parents get old. Because now what’s happening is with the lack of a joint family system, it’s really the children who are dealing with the parents without much support and we’re kind of looking after our mothers and also not knowing how to do it. So I’ll just give you a brief [summary] of my case study, which I wrote in this book ‘A Portrait of Ageing’, if I may just do a bit of advertisement. We’ve written what problems old people face. And I wrote about looking after an older parent. Now, my mother was 79 when she fell down. She had a hip fracture. She had to have a hip replacement after that. The hip was one problem, but I suddenly noticed that one fine day, she got up, or rather when I went to her bed, she looked at me and she said, who are you? So that was a real shocker for me. Finally, we did the brain scan. We did everything. I think that memory loss some people say was because of a urinary tract infection or whatever. But she got her long term memory back. That was just a temporary aberration. But the MRI scan of the brain showed age related atrophy, which means there is a decline in the brain cells, your doctors would explain it better, [because of] which over age you become forgetful. But this was a speedier process and she’s becoming more forgetful. What is happening now is that she has a short term memory loss. So I have to repeat a lot of things and conversations. Even if I leave the room and I come back to the room, she’ll look at me and say when did you come back? Where were you? And I said I was with you all this while. In fact, her favorite question this morning, she looks at me and she says oh, you exist. So I said you are the last person to ask me that. She knows events that happened three or four days ago. She gets a little confused. So it’s very difficult, for someone, for me, to A— see her mother who was in control, she was a working woman, she brought me up, to see her so helpless and B— looking after her. I’m a working woman, so looking after her 24 hours a day, we needed to get health attendance and support for that. 

AB: So Dr. Bangar, I wanted to ask you, there’s been studies which showed that the mental processing speed slows down from about 20 years and then recent studies have shown that actually it’s at 60; where our brains are only affected from 60 years onwards. So can you give us your version of it, your feedback with your experience? What do you think?

Dr.  Santosh Bangar: First of all, thanks very much for inviting me and it’s a lovely forum to share my thoughts. So, as you rightly pointed out, yes, there is a deterioration or decline in the brain cells right from our second decade. And because there are so many brain cells, trillions and trillions, the process is so slow that the actual manifestations happen only in the fifth or sixth decade of [our] life. So by that time the damage is already happening there, the degeneration is happening there. But when we talk about, I mean this is all normal aging, but when we talk about the disease process, for example Alzheimer’s type of dementia, which is the most common type… And we’ll come to what’s dementia and what is Alzheimer’s, because that’s a very common question people have in mind when the Alzheimer’s Disease process starts. So the brain cells die at a very rapid rate. So the analogy I give my patients is to imagine a lawn mower going berserk and chopping all the grass that is there in the garden. So it’s that kind of advanced disease process that happens. 

AB: And can you explain to me while you’re discussing— Alzheimer’s type of dementia as a statement you made. So it’ll be very helpful for all our viewers to understand what is Alzheimer’s, what is dementia and what is the difference between the two. 

Dr.  SB: Yeah, this is, as I said, a routine question that I answer maybe ten times in a day, on a busy clinical day. But dementia basically is a syndrome, and by syndrome I mean a constellation of signs and symptoms of a brain disease. So the common symptoms that people come up with is forgetfulness or not remembering recent conversation or where they put their belongings and things like that. And asking the same question over and over again. Now, mind you, this is different from say— when we go to another room and we don’t know why we went there or we open the fridge and we don’t know what we are looking for. So these are different as opposed to what we are talking about in seniors, because age is the single most risk factor for dementia. So it’s not a disease exclusively for seniors, but the majority of them are seniors, so 60 plus and above. So that is dementia. So the most common symptom is short term memory loss or forgetfulness. Then the other brain functions, which a lot of people don’t attribute to dementia like loss of communication skills, reading, writing— this happens much later in the illness— losing the ability to say, ride a bicycle or know how to swim or how to brush your teeth and so on. So that causes problems with their day-to-day activities and that’s when the strain on the carers or the family comes in. So as I said, dementia is a broad umbrella term, it’s a constellation of symptoms and signs. Now what is Alzheimer’s? Alzheimer’s is a disease of the aging brain. Now when Alzheimer’s disease causes dementia or gives rise to dementia, it is called Alzheimer’s dementia. So it is as simple as that. But what is this Alzheimer’s disease? Because the moment we say that, people get very nervous. So basically it is an abnormal protein that is deposited in the normal brain cells, which eats up the normal brain cells, and hence, all these problems start. I mentioned about the short term memory loss and all the other language ability… you know, loss of their judgment and social skills and social demeanor and all of those. So loss of decorum, all of that is part and parcel. 

AB: Okay, so dementia is the big umbrella term and tell me, do things like lifestyle, diet, smoking, consumption of alcohol, exercise, reading habits— do all these things make a difference at all in whether you develop cognitive issues or not? 

Dr S B: Yes. So lifestyle plays a huge role in this. So you mentioned obesity, lack of exercise, smoking, excessive alcohol consumption, sleep, there is more and more emphasis on sleep…

AB: Absolutely, that’s very true. Sleep is such an important thing and more and more people seem to be sleeping less. But the other thing I wanted to discuss is dementia awareness or Alzheimer’s awareness has gone up so much more and one of the reasons is that there’s a lot of films and books that have been covering it. But the point is that popular culture is not always accurate. What is your view on that, Dr.  Bangar? Do you feel, is there a book or movie you can recommend for someone who’s trying to learn about this?

Dr S B: I’m glad you brought this up because social media, the film industry, and other magazines and so on, they’ve helped us immensely in improving the understanding of the general population. Some of the movies do document that incorrectly, and some of them do ask medical experts to either tally the story they have written and so on. But I have yet to come across, to be honest, something which accurately demonstrates what a person goes through. 

AB: Priya on that note, I wanted to ask you, I know you’re an avid reader, so is there a book or movie where the tips really helped you or that gave you solace, that helped you in any way?

PS: I do agree with Dr. Bangar that the movies and books, in my point of view, tend to romanticize the disease. They make the parents so lovable. They have Alzheimer’s, we listen to music, they are childlike, and it’s so lovely— but it is not lovely. It is heartbreaking to see a parent become a child and you become the mother. To hear them talk like a child, to argue over chocolate. She’s forgotten how to brush her teeth, Dr. Bangar, you know you said you forget things, so that’s what she’s forgotten. It is heartbreaking. It is adorable for a two year old, but it is not so adorable for an 81 year old. I’m sorry. And to live through that every day, after day, after day, it gets too much. So I don’t agree. Any movie, any book that romanticizes it I think it’s just… you know, you’re just, yeah, maybe giving hope, you’re trying to build the moral of the caregiver, but we are living in that reality. We know what it is. You can’t fool us. It’s just not lovable at all. The personality changes, I don’t know why people don’t talk about that. My mother is on a huge regime of antidepressants because I think there is so much anger, there is so much frustration. This is not the person who was my mother. The person who she is now is not the same. How does one deal with that as a caregiver? How does she deal with it? Because there are moments when she’s aware, and that’s what makes her so frustrated and so angry also. She’s been so independent, so now that she needs help she hates it, because after the hip fracture, she’s lost the confidence of going to the loo, or just the general things. So there is that added pressure. So the whole frustration, anger, depression, I mean, I don’t know. There is also a lot of repetition in what she watches. I think that there were red flags, that’s the other thing I would like to say. There were red flags one could have seen. For instance, even before she fell, she stopped going out, and she was a working woman. She just started dressing down. She was not looking after her parents. She was watching the serials, and she was watching the same serials over and over again. And if a new episode came in those serials, I had to actually look and tell her, no, none of your favorite characters have died. So you can see it. She will watch the same serial over and over again, which is, you know those three limited serials that she has, she watches them again, where she knows the ending. She doesn’t want anything unpredictable. 

AB: So, Priya, I wanted to ask you, what is it that actually helps your mom?

PS: What helps her is predictability, the same pattern, to let her know that she is in control while helping her, but at the same time not letting her know that she’s been helped. She has to be in control. If I want her to wake up— she hates waking up early, so if I say get up now, it’s 10:00 or whatever, she will get angry. But then if I say— do you think you want to get up, you can come and watch a movie or something… You have to make it sound like it’s her idea when actually you are telling her what to do. So it’s just the way you handle things and as far as what’s helped me is just talking to friends, talking to people. There is no book, no write up that has really helped, and talking to the medical doctors has also helped, of course.  For me also the unpredictability is something I can’t deal with. I really want to know what is going to happen in the next two years, next five years, where to go, what to look forward to. I want that roadmap but I don’t know if the doctors can give me a roadmap for a disease like this. 

AB: So that’s a great question. Welcome to the show Dr. Renjen. 

Dr.  P N Renjen: Good evening. 

AB: Good evening. Thank you for being here with us today. So we have a great question for you from Priya who’s looking after her aging mum. Her mum is going through short term memory loss and depression and she would love some sort of a roadmap of over the next two years, the next five years of where they’re heading to. 

Dr. R: Well the question is very appropriate, but the point here is that it’s very very difficult for me to suggest a roadmap for a dementia patient. It’s very rightly said. It is not what the textbooks or ebooks write about dementia, but every individual of dementia is a book by itself. They behave erratically differently. What I would like to first stress upon is that when one starts treating or diagnosing dementia, one must be sure as to what is the type of dementia they are dealing with. After all, dementia is a broad term which includes a large number of neurocognitive and neurodegenerative disorders and each of these take a different course. Now say for example, I for one don’t like treating dementia till I know what I am treating broadly. In my mind I would classify whether I am not missing a treatable dementia. Every dementia is not degenerating; we have to look for treatable dementia. Number two, a very common mistake is what is called vascular dementia— A dementia we have done a lot of work on. Vascular dementia is not the same as Alzheimer’s dementia. You may have the two together in the same patient. A VD- Vascular dementia may convert into an AD [Alzheimer’s dementia]. So Priya’s question becomes very relevant, what do I do? I would go all out to treat her vascular dementia with medicines, treat them with cognitive therapy, treat them with all sorts of inputs, because I know that I could improve the quality of life of this patient. 

AB: Okay. And coming to what you’re saying, you’re saying it’s absolutely imperative that dementia is classified as what kind it is. So tell us, what tests does one need to do and what age should people be doing the test, and are they available to do at home?

Dr. R: Well, the tests are all available. After all, a patient or, say, a person comes to me, and I say it’s dementia. Now, really, I want to know, as I said, is it the right hemisphere or is it the left hemisphere? I want to know, has it involved the frontal lobe, has it involved the temporal lobe, has it involved the parietal lobe, or has it involved the occipital lobes? Depression is not dementia. It’s pseudo-dementia. So that’s exactly what I’m saying, that you have to really ascertain whether there is dementia at all before you start treating it. And as I just said that I would like to know, which area of the brain is involved? Then the next thing I would do, I would do my own examination, which is called the Mini-mental State Examination, which is known as MMSE. Then maybe I’ll refer this patient to an experienced psychologist or neuropsychologist, who would further help to tell me which areas of the brain are involved. Is it the frontal lobe or the temporal lobe? For example, you know that Alzheimer’s disease doesn’t involve the frontal lobe. It predominantly involves the temporal lobe. Next step is the imaging. I’ll do an imaging. Now, what imaging will I do? Well, we do an MRI scan, and now we have got a molecular imaging, what is called a PET-MRI or a CT-MRI. We can do a DOPA scan then, to say, yes, that this patient has this form of dementia. Then you take off from that. 

AB: I see. And Dr. Bangar, are there any tests that you would recommend to the patients to do when they’re, in fact, before they’ve got to a stage of cognitive impairment of any sort?

Dr S B: As we all know, it’s insidious and a very slow course of a disease. So there may be instances of impairment in their personality, short term memory loss, and so on and so forth. So the histories of paramount important answers rightly say— neuroimaging and neuropsychological tests kind of helps us to put the jigsaw pieces together to come to a definitive conclusion. But certain tests of cognitive [impairment] day-to-day are like, we can do bedside testing, asking them about orientation basically, like what day is it or time, what they had for breakfast and things like that, [to check] whether they are able to recall accurately. So anybody can do this at home. All of those little things tell us a lot of information. So these can be used as bedside testing. As sir said, MMSE, which also can be done by not a very well trained person as it’s a basic test. We give them a circle to draw and ask them if this is a clock, then please put all the numbers inside and those are the tasks. There’s something called a trail making test, so alternate sequences of ascending letters and numbers. These are the little things which we can do at the bedside and certainly a lot of testing by the neuropsychologist will help as well. 

AB: Okay. And Priya, did you find any tests or signs that you would say one should watch out for?

PS: As I said before, once my mother fell, of course, then she suddenly lost her memory. It was a very sudden concept of the short term memory loss caused by that fall, where she had to have a hip replacement. But before that also, I used to find a lot of anger, a lot of insecurity about herself. She would want to write everything down in terms of, she was living alone, so when we are coming, she would write it down on a calendar, 1:30 or 2:30 and get the days a bit mixed up. But then one thought is also because she was 79 at that point. She’s now 81, so for the last three years I’ve been dealing with this. So in her late seventies, one thought that this was just forgetfulness. She also stopped working ever since she was 60, just staying at home, and one didn’t trouble her. I think the whole thing was that there was insecurity. There were a lot of red flags now that we look at it. As I told you earlier, she stopped dressing up, she stopped going out, she stopped interacting. Her whole conversations also became related to one or two topics and they were very repetitive, so on the same topics. She was very well aware of what’s happening, she was reading the newspaper, so she was not out of touch with what’s happening, but she was just focusing on just two or three things mainly. And from her there was a personality change. She became more insecure, more less confident of herself, etc. So I saw all those signs which later on I realized that they were, I think, red flags of depression more than dementia, the doctors would know. Now, what she’s going through is definitely short term memory loss, like forgetting things, forgetting what she had for breakfast, forgetting people who come. She remembers, but like someone came last week, she still thinks he came yesterday. So she gets these people confused, but at least she’s remembering. We did the MRI, Dr. Renjen, as I pointed earlier, which said that she’s suffering from age-related atrophy. But beyond that I can see degeneration happening in terms of the memory. Apart from that, the cognitive functions are more or less okay so far. 

AB: So Dr.  Renjen, I wanted to ask you one thing. So like Priya said earlier, you need a full time carer. Are there any other solutions that we can offer people listening in?

Dr. R: See, the point is obviously, as Priya said, the management of a patient of dementia and cognitive disturbances is not only drugs, but it is much more than that. Unfortunately, we neurologists don’t have any wonder drugs for Alzheimer’s or any neurodegenerative disorder. So my advice to the patients and my advice to the caretakers are please look after four or five things. First, avoiding these patients from falls as they are a very bad thing. And you can imagine if a patient with dementia falls down in their seventies and eighties, they have a fractured neck or femur. Once you have a fractured neck or femur, you’re in bed and the decline starts. Second, with age there are a lot of metabolic factors which play a role. For instance, they lose sodium from the brain, which is called Cerebral Salt Wasting [CSW] syndrome. I tell you, very often, in my own hospital— the Apollo, patients are brought with altered sensorium, altered levels of consciousness and they just have low sodiums. So please watch out for that. Third bedsores, fourth diets, and fifth chest infections. Their diet has to be taken care of. And of course with that physiotherapy. And I don’t know, maybe Dr. Bangar will agree with me, if the patient is not regular with the drugs, except that he looks after his diabetes and hypertension, it’s fine with me. But I want him to be in total care. And I tell you one thing that the care of a dementia patient is not an easy job, it is not at all an easy job. Because they develop a lot of problems, in the sense personality changes, they are restless, suspicious, and angry. So it sort of works up the whole family. 

AB: Yes, absolutely. And Dr. Bangar, would you like to add anything to how we can help people or even games that people can start doing at an earlier age to prevent getting to the state, so games or apps they can use?

Dr S B: Yeah, so I would just add to what Sir said— it’s a disease not only of the person, but it affects the whole family. So when we are treating, we treat the whole family. As Priya would agree that it has taken so much toll on her own well being, both mental and physical. So we include the family right from day one because the person’s dementia will slowly and gradually decline and they may not remember going forward what they were like say a few months ago, or who’s looking after them. Like if it is their son, they may mistake them for their son in law or brother, and so on and so forth. So it is important that you keep fit as an individual looking after your loved one, because if you’re not well, your loved one is going to suffer immensely. So coming to your question about how we can deal with this, because it is a dreadful illness, there is no cure for that. It’s been around for so many decades and decades. There is no cure. There are more than 250 molecules which have failed trials. So it is a disease which is not going to go away anytime soon. And the incidence, or what we call as prevalence is increasing day by day because people are living longer. But having a healthy and a balanced diet, quitting smoking, drinking in moderation, six to 8 hours of good quality, refreshing sleep, getting your eyes and ears checked— because hearing loss is also an indirect risk factor, more and more studies are done these days— so all this, what we call as annual health checkup, must not be taken lightly. We should have our vitamins tested. So vitamin B 12, sir talked about reversible dementia. So vitamin B 12, Hypothyroidism, and vitamin D is coming a long way. So all these are treatable and preventable things not only for mental, but for your physical health also. So eating salt in moderation, avoiding sugar. Exercise is also very important. Only 30 minutes every day. It doesn’t have to be a vigorous exercise. Even moderate brisk walking is good enough. And that is along with your daily walks. You may be walking to work, walking from work and walking during work, but 30 minutes of dedicated walking, half an hour every day is very important. And you talked about crosswords and sudoku— those are all brain exercises and they can help immensely. So there are a variety of them. You have apps because we seem to do everything on the phone these days. So there are apps at your fingertips. But keeping your brain active is very important. And do not forget social contact, because that’s also a risk factor. 

AB: Thank you for that, because Priya, in your article, I know you mentioned limiting social interactions did affect your mom’s health. But Dr. Renjen, I have the last question for you and that is: what other diseases of the aging brain would you classify that people should watch out for?

Dr. R: Well, see, there is Alzheimer’s Disease, then we talk about Parkinson’s disease. And I think when we talk about dementia, we talk about a progressive dementia. Alzheimer’s is the first and Parkinson’s disease is the second most common neurodegenerative disease. It’s very interesting that 10 to 15% of patients with Parkinson’s disease have dementia at a later stage of the illness. But when Parkinson’s disease starts, it starts with a tremor on one side, difficulty in walking and slowness of movement. So that is what Parkinson’s disease is. And I must tell you that Parkinson’s disease is absolutely misdiagnosed. I won’t say Parkinson’s disease as described by Sergey: Parkinson in the 8100s was a curative disease. But I have a wonderful drug which is called L-Dopa and Syndopa which to a large extent improves the symptomatology of the patient. Now it’s a progressive disease. It’s a progressive neurodegenerative disorder. So I think when you talk about dementia, when you talk about cognitive function, please don’t localize yourself to that. Go a little further. Is it really a cognitive disorder? Is it really [in the] membrane? And Dr. Bangar, very rightly said, mental health is the mental and social well being of a person. If I keep on fighting with my neighbors, if I am an introvert and the whole day I’m just sitting and grumbling, if I don’t have any social life, I’m 100% going to have dementia. So that is my advice to people whose parents have dementia. Be cool, be kind and be sympathetic and empathetic towards them and you’ll get the results yourself. 

AB: That’s wonderful advice. I’m going to do a very quick summary before we go. So Priya, what is the toughest challenge as a caregiver that you’ve had to face. 

PS: All that Dr. Renjen just said— be cool, be calm, be wise. I think all those are my biggest challenges because I begin the day by saying I will not lose my temper. I will not. But there is something… you try not to at least in front of her, but there is something that just gets you every time. It’s a very difficult ride for me also. I’m going through the same pattern over and over again. 

AB: I wanted to ask you what is the biggest tip that’s helped you or what’s helped you the most?

PS: It’s not personal. And someone told me that this is not your mother anymore. If you can distance your mother— the individual from the patient, she is now a patient— that has helped me. Because I have to take those three steps away. Otherwise I keep wondering what happened to my mother? Is this my mother? Do I scold her? Sometimes she’ll have a whole bowl of kaju, so you have to tell her don’t eat this, eat that. She’s argumentative. You have to sometimes tell her not to be rude to her maid. So you become the parent here. So I cannot imagine her as my mother. So someone told me that that is not your mother. Now she is a patient and I think that advice has really helped me deal with her. 

AB: Thank you, Priya. And lastly, how do you care for yourself?

PS: How do I care for myself? By working. I never thought work would be so helpful. But yes, I totally agree. The advice given here— go for that walk. It has really helped me. In the last three or four months, I’ve been with my mom 24/7 because we had some issues with her attendant. So I needed that walk. That really clears my mind. 

AB: Wonderful. Thank you. Dr. Bangar— three signs that people should seek help. 

Dr S B: As a geriatric psychiatrist, I would say memory loss is one, change in your personality, and get your depression or anxiety treated. 

AB: Thank you for that. Any exercise to delay cognitive decline?

Dr S B: Well, walking is one of the best. So we don’t have to be a very religious gym goer, but walking or a treadmill, cross training, whatever you fancy, swimming. But other exercises which I was not able to touch upon are music, yoga, dance, zumba— all those are very useful and effective techniques. Also having a pet is very soothing for the patient and the family as well. So there is animal assisted therapy, as we call it. So that’s very useful. 

AB: Lovely. And one important way of giving support to the person. 

Dr S B: So this is a little bit personal to Priya, but as long as you know you’re looking after your mother, it is all that matters. If your mother cannot acknowledge you as her daughter, that is part of the illness. So don’t take it very personally. Don’t feel guilty that you’re not doing enough. Because one of the major things that suffers in the carers is their own mental health that is affected. They feel guilty, they go through a lot. Insomnia is usually common. 

AB: Thank you, sir.  Dr.  Renjen, one mistake, sir, that you think people make when it comes to mind related issues. 

Dr. R: One thing which they mistake is that they think everything is fine. Where I give most importance is— a change in the personality of a patient. If a patient’s family tells me that, doc, she was a very nice lady, she used to walk, now she suddenly became withdrawn, there’s something wrong. 

AB: And one tip to caregivers. 

Dr. R: Caregiver— please be cool. Treat your patient, whether it’s your mother [or father], as a carer or as a doctor, doesn’t matter, but treat them with a lot of sympathy and empathy. 

AB: Thank you. And one piece of advice to keep our brains working. 

Dr. R: Two things are very important, as that’s what I do. One, regular exercise. Number two, keep your brain working. Keep on reading something. I must tell you, I read every day for about an hour and a half or two. The day I don’t read, I think something is missing. If I go out for a holiday, for a week, and I haven’t read anything, then when I come back, I’m a zombie. 

AB: Lovely. Thank you so much. Thank you for joining us today and thank you for the viewers. I hope you learned something new and I hope we’ve got you closer to leading a happier, more hopeful and healthier life. If you like this chat, please share it, please press like and please subscribe to this channel. Thank you.