By Elizabeth Kiefer
An occasional memory lapse does not signify a larger problem — most of the time. Our brains can feel fogged over for numerous reasons, from work stress to overstimulation to the desperate need for a good night’s sleep.
Though in some instances, there might be a more serious issue, explains neuropsychologist Jessica Caldwell PhD, the E.L. Wiegand Chair and Director for the Women’s Alzheimer’s Movement Prevention and Research Center at Cleveland Clinic.
“Women are about two-thirds of the people with a current Alzheimer’s diagnosis,” says Caldwell, whose research focuses on the population of women with a family history of the disease, and how lifestyle changes in the present might help them mitigate brain health challenges in the future. The clinic is also educating women, and the general public, about Alzheimer’s disease: a broad term for memory and cognition loss, which is not a normal aspect of aging and is serious enough to interfere with daily life. While an Alzheimer’s diagnosis can be alarming, it’s important to know that early evaluation, and intervention, are available and impactful.
“We are looking at everything from the most common risks women come in with to how they do over the course of treatment to how they make changes, and then also inviting those women to participate in other types of studies.”
We spoke with Dr. Caldwell about why it’s crucial to take our brain health seriously earlier in life, what’s happening to a mind going through menopause, and when a “normal forgetting episode” crosses into something else.
Can we start by talking about why it’s pivotal to break out women as a specific group when it comes to studying brain health, and specifically Alzheimer’s?
I [see] patients who are women that have a family history of Alzheimer’s disease. I look at the impact of stress and estrogen changes across age 30-60, so the menopause transition, and how those two things might come together to really alter the way that inflammation happens in women’s bodies and the ways our brains work when we’re trying to learn and remember. We know that hyper-inflammation and peripheral inflammation are not great for memory, and I’m wondering if these have a long-term impact on brain health.
We also know that men don’t experience a similar shift. They have a much slower loss of testosterone, and it happens later in life. So this study is one that has to be done in women, and we need it because these studies just haven’t been done in the past, because women haven’t been as big a focus of the research as they’re now becoming. It’s not about the need to compare women to men; it’s about trying to understand what factors may underlie women’s greater impact from Alzheimer’s disease.
What is the relationship between that estrogen shift around menopause and memory?
It’s complex. Half the population goes through menopause, but not all women develop dementia. It’s not as if losing estrogen equals getting dementia later. What we do know is that, throughout the memory system in the brain, we have estrogen receptors — this is also true for men — and these estrogen receptors promote stronger memory and support the health of neurons in the regions where they exist. When women have that steep drop of estrogen during menopause, their brains have to adjust to not having that estrogen around, which impacts memory in some women who are sensitive to it.
What we need to figure out is: Who are the women most sensitive to that estrogen change when it comes to memory? And what should they be doing about it? Because there do seem to be women who recover less well after menopause when it comes to memory, and it may be that those are the women who have the most risk of experiencing memory problems later. But it’s not everyone.
Can you share more about the risks, and about lifestyle changes that can help mitigate them?
Some of the things we know we have control over in our lives account for up to 40 percent of dementia [cases] — which is not to say it’s someone’s fault for not having done a behavior that’s healthy. It’s just to say how important it is to exercise, to not smoke, to not drink too much, to get enough sleep. There are so many pieces of day-to-day life we can impact. Some of them we may be less able to impact, like high blood pressure or diabetes because it runs heavily in families. On the other hand, there are things you can do with exercise and nutrition that can counter those types of risks. It’s important for people to know that it’s not too late when you’re 30, 40, or 50 to change your behavior in a way that will impact your health later — even decades later.
You mentioned stress as a risk factor. Can you elaborate?
In preliminary analyses, we’re seeing that more than half of women in our registry are reporting daily stress, and that can really take a toll on memory systems. Same thing with depressed mood: That’s a risk factor for dementia that not many people are aware of.
One of the big take-home points that we’ll be publishing soon is that there are things we can do [for our brain health] that can relate more to our mental health or social health and I think are overlooked.
Do you see women waiting to seek care, or minimizing their symptoms, when earlier intervention could be beneficial?
I don’t see that in my research but anecdotally, in a memory clinic setting, what is seen are men coming in earlier for memory assessment, oftentimes because women are bringing them in. Women have this caregiving role, whether for children or spouses or extended families, and oftentimes we put others’ health first, including in this way. It’s important for women to hear this younger: Your health needs to be on your priority list because it’s not on anyone else’s. It’s up to you to value yourself and not feel bad about taking care of your own health.
Since becoming a mom, I sometimes feel like my mind is full of folders with corrupted file paths. I know the information is there! I just can’t get to it!
You know, there are so many normal reasons in our life to forget things. Women tend to pick up on forgetting more than men, so it’s on their minds more, and if you have a parent who is going through dementia it’s amplified beyond that. It’s important to know about the risks for dementia, but it’s also important to give yourself a break if you have a minor forgetting episode and don’t have another one for quite some time.
What defines a ‘normal forgetting episode’?
Most people, as we age, will have a slight decline in memory sharpness. Forgetting slightly more often is, for most of us, part of normal, healthy aging. Beyond that, there’s everything from a bad night’s sleep, to being chronically sleep-deprived, to things like having a young child or having many tasks at work or on your household to-do list. The more you have to do, the harder it is to get it all done flawlessly.
Another big thing is distraction. If you’re trying to recall something and you’re in a space that’s loud, or you have competing demands, that will make it harder to access those ‘file folders.’ And then there’s menopause. The hormone changes can lead to both distraction — for example, in the form of hot flashes, which make it hard to focus — and because it’s impacting your memory system briefly.
What might be considered something other than a “normal” forgetting episode?
My guidelines are to think about how often you’re forgetting and how significant it is. So, for example: If you’re forgetting once a month in the context of stress, that’s probably not a big deal. But if you’re forgetting a conversation multiple times per day and having to get reminders, or multiple times per week, that’s a sign you should probably go get checked.
On the significance side, if you forget the name of someone you worked with years ago, that’s probably not a big sign of concern. But if you forget the name of someone in your close social circle, that’s more of a concern.
If you do decide you want to check things out, where should you start?
I recommend people start with their primary care doctor. Then, if they have a concern, they can refer women to the specialist who might take a closer look at memory. That could be anyone from a neurologist, who is going to do some brain scans and blood work; to a geriatrician for older women; to maybe even a women’s health specialist to take a look at hormones if that might be an age-related issue; to a neuropsychologist, a PhD who has expertise in brain-behavior relationships and will take a look at thinking with memory tests.
What does treatment for memory loss look like today, and how do you see that evolving in the future?
At present, and for a long time, if you have confirmed memory problems that are thought to be related to something like Alzheimer’s disease, there have been medications that can give your memory system a boost but they do not impact or stop the disease itself. Now, we also have medications that can take Alzheimer’s-related debris out of the brain. These are complex medications that you have to be vetted to be on because of the potential side effects. They’re also expensive and require an IV. It’s a kind of infusion medication.
In the future, I would expect to see easier-to-take medications for clearing debris of the brain that are cheaper, and I would also very much hope to see prevention stepping up on a bigger world stage from both a lifestyle and a medication perspective. I think within the next 10 years, those things should look different and I’m hopeful they will.
If Alzheimer’s is something you’re experiencing personally — either yourself or with someone in your circle — how would you advise people to broach the topic?
From the perspective of talking about your own memory, I would say: Be your own advocate. Tell your doctor, ‘I’m concerned about my memory, it’s different from before.’ If you have a family history of dementia, let your doctor know. That’s one communication piece that’s really hard to do sometimes.
If you are a family member or friend of someone who is having what looks or seems like a memory change, sometimes people with memory changes don’t realize it’s happening and it’s tough to bring that subject up. But in the end, it’s important that the people you care about get an early diagnosis if something is a problem — or, just get reassurance if it’s not a problem.
I encourage people to talk with their loved ones as directly as they can. I think something is different about your memory. Would you go in and have it checked? It is very challenging. Building resources to help care partners is a priority of our lab here and also of many others.
There is a lot that we can do in terms of using healthy behavior to stack your odds away from dementia later on. Right now, at our Women’s Alzheimer’s Movement Prevention and Research Center, we have openings for women 30-60 who have a family history of Alzheimer’s. We would love to see more folks.
This interview has been lightly edited for length and clarity.