Dr. Mia describes the domains of memory/cognition:
Memory mimickers that can confound memory evals:
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Music & disclaimer
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Welcome back to ask Dr. Mia podcast and I am Dr. Mia. I am doing a three part series on memory. This first part is going to talk about different aspects of memory. There are actually different parts of our memory that we all need in order to function independently. I'm also going to talk about some confounding factors or what I call memory mimickers, meaning, these are things that I evaluate in my patients to see if it's truly memory problem, or it could be something else that is presenting like memory problems. In part two, which will come out in the next episode, I'm going to talk about safety issues related to mild dementia and the four main types of dementia one can evaluate for. In part three, I'm going to talk all about managing behavioral problems in more moderate to severe stages of dementia as well as all about the care partner and other family members. So stay tuned for the three-part memory series.
[00:01:15] But for today. I want to start by talking about Barbara. You may remember Barbara from the last episode, talking about why so many Alzheimer's drugs fail and barbara is a composite patient of mine who is in her seventies. And originally came to see me because her family has noticed some memory problems. She herself has noticed that she seems to be asking the same questions over and over, usually a day or two days right after her family has already told her the same conversation before.
[00:01:54] So when she first came to see me, we talked a little bit about what is normal aging. Some of the symptoms that are normal aging are things like going into a room and forgetting what you went into the room for? This is usually because we have new triggers that make us think of something when we walk into a new environment. So for example, if Barbara went to the basement to look for a screwdriver, she was thinking about the screwdriver when she went into the basement. But when she went into the basement, she saw the washer and dryer, and remember that she needed to do laundry. So then she started doing laundry and completely forgot about the screwdriver. This happens to a lot of us, even those of us who are not older adults. Definitely something that is common and is a normal part of aging.
[00:02:49] What is not normal aging when it relates to someone's short-term memory is it's really having a very short interval of not remembering, where you talked about going out to see the doctor in the morning and then by the afternoon, that person has already forgotten. The time interval between when you tell someone something and whether they can remember it. The sooner, the more recent events should be easier to remember, cause you just talked about it. But in people who have short-term memory problems, that's when they have problems recalling recent memory. A lot of times people say, oh, my mom's memory is great. She can remember what she did in elementary school versus I don't remember that. In fact, people's long-term memory is usually preserved in many different types of dementia, especially in the beginning. So just because mom can remember something from elementary school doesn't that mean that she has short-term memory problems. It is also a problem with forming new memory. So if you wanted her to learn something new, or do something that's different, it may be difficult for Barbara to do.
[00:04:07] The next domain of memory is what's called executive functioning. And this is a domain of memory where most people don't know the words, "executive functioning", but in fact, we all need to plan and organized a series of steps in order to function independently. For example, planning an elaborate dinner, like at Thanksgiving. It takes a lot of executive functioning. You need to know where the ingredients are, how long to cook something, switch tasks between something that's stirring in a pot versus something in the oven. And this could be quite difficult for people who have executive functioning problems. Another common daily activity is driving. Driving involves a lot of different inputs. We have to know where to turn. We have to keep the roads in our mind, unless it's a very familiar road that you store as a procedural memory or automatic memory, but going somewhere new and reacting to other drivers as well as the route takes quite a lot of executive functioning. What can be normal as we get older is that it may take longer to cook an elaborate meal and you may need more prompts, like written notes and using timers. But what is not normal are completely not being able to put a recipe together. There are some types of dementia where the folks don't actually have a short-term memory problem, but they actually have quite a lot of difficulty doing things that they need to do for themselves in daily life. And that could be in what's called a frontal temporal dementia or a Lewy body type of dementia.
[00:05:56] Going back just one step. I wanted to make sure the listeners know that dementia is an umbrella term, meaning that someone is having difficulty doing their activities of daily living things that they need to do on a daily basis to remain independent because of cognitive problems. If someone is wheelchair And they can't go out And go shopping for themselves because they're not driving because of their physical disability, that's not dementia. So sometimes we need to sort out what is because of memory and what is because of physical limitations, like shortness of breath. So dementia is an umbrella term. But Alzheimer's. disease is the most common type, which is the type of dementia that is really prominent impairment in short-term memory.
[00:06:47] Next domain is visual spatial memory. This might be where someone is having difficulty knowing where things are in space. They may go to a new house and despite saying, the bathroom is this way, they might still have trouble figuring out where the bathroom is. That could be normal. Parts of aging. Sometimes people may exit on the wrong exit on the highway because they got distracted talking. What is not normal is getting a lost in more familiar places or places that you've gone over and over for years that usually spell some problem with visual spatial memory. Sometimes strokes may affect the visual spatial domains of the brain and that can cause us problems in terms of finding oneself in space.
[00:07:37] Language domain of memory, that's another common one. It is pretty normal part of aging to forget acquaintances names or feel like the names are at the tip of their tongue, but you'll think of the name at a later point. It's also, normal, if you accidentally mix up your children's names, especially if they all start with the same letter. What is not normal are having difficulty coming up with common words or you're noticing that your loved ones' speech is frequent substitutions with alternative words for a word that they can't remember what to say. You may also notice that someone is actually withdrawing from social conversations because they're having difficulty coming up with the words and conversation. There are certain more rare types of dementia that predominantly focus on the language domain of memory loss. Alzheimer's disease can oftentimes also affect language especially as short-term memory problems progresses.
[00:08:42] Another domain that we check for is attention: our ability to hold things in our working memory being able to pay attention. For example counting the months of the year backwards or or being able to subtract seven from a hundred and then subtracting from 93 and so on and so forth. This could be a domain that's commonly associated with mood problems. When one has depression and anxiety, oftentimes it makes people have difficulty paying attention. Sometimes people have had lifelong learning disability and they were never diagnosed, never did well in school and having difficulty paying attention.
[00:09:27] The final domain is the speed of processing: just how fast or slow our thinking is. There is some normal slowing of how fast our thinking is with aging, as well as more limited ability to multitask. So just to review the domains of memories are: short-term memory, executive functioning, visuospatial memory, language, attention, and speed of processing. And looking at different aspects of memory can often tell the doctors what type of memory loss someone has. One thing that I do want to note as a caveat is that memory tests, cognitive tests, may not be accurate for someone who is highly educated, someone who's very bright, mostly Caucasian population who speak English. So it is not always a good reflection of people of color and people who are immigrants and from other cultural backgrounds where non-English language may be their first language.
[00:10:35] So now we're going to switch gears a little bit to talk about some confounding factors that one can check for as you have noticed memory problems. As a geriatrician, one of the first things I look for is the list of medications. There are a lot of medications that are what's called anticholinergic, meaning they deplete a chemical, the cholinergic chemical that we all have around our brain for memory and attention. And these could be a common things that are over the counter, like Benadryl or Tylenol PM. Anything that contains PM usually contains Benadryl or the generic name of Benadryl, which is diphenhydramine. Sleeping aids that are over the counter often have similar properties. Prescription like benzodiazepines: Ativan, Xanax, Klonopin. Those type of medications are what I call alcohol in a pill and they can also negatively affect one's memory. Bladder medications for urinary incontinence, oftentimes are anti-cholinergic as well in the sense that the cholinergic molecule affects our bladder as well. And in order to These medications may affect the brain. All of this is to say that it doesn't mean you can never take these medications, but you should speak with your doctor and pay attention to whether these medications are treating what you think it's treating and whether it's worth stopping if you're also noticing memory problems.
[00:12:22] Another confounding factor is untreated obstructive sleep apnea. And this is when you might have to ask someone else to see if you snore at night, if you stop breathing at night. If you're not getting enough oxygen in your brain overnight, It can be very difficult to feel energized and refreshed and attentive the next morning. And oftentimes people who have obstructive sleep apnea may fall asleep at a drop of a hat during the day. They May sit down to watch TV and then immediately falls asleep and snore. One does not have to be overweight to have sleep obstructive sleep apnea. CPAP is the gold standard treatment for sleep apnea. And a lot of times my patients tell me that they're having difficulty tolerating the CPAP and I really encouraged them to talk with their sleep doctor about what other alternatives there may be to treat the sleep apnea, because it's not only good for your memory to get a treated, but also good for your cardiovascular health.
[00:13:28] As I mentioned earlier during the attention domain, mood issues such as depression and anxiety can definitely affect one's memory as well. People who have had lifelong psychiatric illnesses, such as bipolar, schizophrenia, may have difficulty performing on some of the cognitive tests. Sometimes it can be difficult to sort out which one came first: did the depression lead to mild memory loss? Or is it the mild memory loss that makes someone conscious of their inability to remember and make them depressed? They could be happening at the same time and it's very common and difficult to sort it out. Sometimes what a lot of primary care doctors and me as memory specialist may decide to do is go ahead and treat anxiety with the antidepressant and counseling for a couple of months to get the mood symptoms better, and then reevaluate someone's memory again. Head injuries, B12 deficiency, and thyroid problems, are other common reasons for memory loss. B12 deficiency is pretty common. For people who are vegetarians, B12 supplementation may be especially important. Low thyroid can oftentimes present as memory problems as well.
[00:14:50] One other confounding factor that I have not mentioned is alcohol. Our ability to tolerate alcohol changes as we age . Women are also more sensitive to the effects of alcohol than men. So the amount of alcohol for older men is two drinks per day, which is 14 drinks per week, if one is drinking every day. For women, the recommended amount is 1 drink per day. Without feeling drunk or tipsy with alcohol, the alcohol still can affect our memory and make someone who already has some short-term memory problems worse.
[00:15:30] The last confounding factor that is very important is hearing loss. And this is particularly common, especially in older men. Some couples tell me that one of their spouse actually has selective hearing. They may actually have just general hearing loss, but, as we get older, the higher pitches become more difficult to hear. So sometimes it might be selective because if the husband is having difficulty hearing a higher pitch voice of their wife. But can hear someone who has a lower pitch like their son. If you don't ever hear the information, it's hard to remember that later on. So i really strongly recommend for folks to get their hearing checked, wear their hearing aids, if their hearing aids are prescribed. There are over the counter hearing amplifiers that are much cheaper than hearing aids. I'll put those in the show notes. I have no affiliation with any company that makes them but I also know that CMS is making changes in terms of allowing over the counter prescriptions of hearing aids, which may be a separate discussion at a future episode. Hearing Loss is a very complex and common issue that I recommend evaluation and treatment for, to really optimize as their hearing as well as their memory. Most men are not aware of how important hearing is to their memory, but when i explained to them the important relationship between hearing loss and memory loss, many people are more motivated to get their hearing loss treated.
[00:17:12] So the overarching theme of memory evaluation is really comparing you with your baseline. So sometimes it can be difficult to tell what is a change from someone's baseline, particularly if they're highly intelligent or bright, or if they have had lifelong learning disability that may or may not be diagnosed. It's difficult for the extremes of cognitive test performance to really tell what is a change. So i hope this is a brief summary of the different domains of memory loss, as well as some of the common confounding factors. Thank you for listening and hope you come back for part two of this three part memory series and feel free to write me a review on apple podcast, share this with other loved ones, or sign up for the email announcement on my website: miayangmd.com, you will get a notification in your email when new episodes are released every two weeks. Thank you!