When is Forgetfulness a Cause for Concern? (Better Brain Fitness podcast)

Josh: Welcome to Better Brain Fitness, hosted by doctors Josh Turknett and Tommy Wood. In this podcast, we will explore the frontiers of how to keep our brain fit and healthy so that we can perform at our best and do the things we love for as long as possible. Let’s go.

All right, welcome to another episode of the Better Brain Fitness podcast. As usual, I’m joined by my co-host, Dr. Tommy Wood. Hello, Dr. Wood.

Tommy: Hello, Dr. Turknett. How are you? I’m good. Thank you. [00:01:00] How are you?

Josh: Good. Excellent. So we’ve got a question today that was a question that’s been submitted by multiple people and, as some of you know, that’s the format of this show.

You guys submit your questions to us and we take a stab at answering them. And if you’d like to submit a question to us for the show, you can click the link in the show description or go directly to brainjo.academy/question and submit it there. Okay, so today’s question initially came from Rose in central Pennsylvania, who said: “my husband and I are in our late seventies and getting very forgetful. How do we increase our memory and how do we know it is just aging and not something more serious like dementia or Alzheimer’s?”

So, great question. As I said, it’s one we’ve gotten a lot of along these lines, so I’m gonna kind of cover it fairly broadly and talk about really the primary [00:02:00] issue that a lot of people notice, which is forgetfulness.

Some version of, I’m noticing trouble with my memory, and I’m worried about it. And usually this is in the form of having trouble coming up with a name, maybe a name of an acquaintance, sometimes somebody more familiar, going into a room and forgetting why you went there, forgetting where you put something.

So the gist is that you just feel like you’re forgetting more things than you should. And the most common question about that is, is this a cause for concern? Could it be the early signs of something serious like Alzheimer’s disease and while people are more prone to notice it, and be on the lookout for it as they get older, I’ve certainly had plenty of people over the years in their twenties, thirties, forties, who have come to me for evaluation of these sorts of symptoms. So it’s certainly not just an issue for those who have multiple decades under their belt, even though that’s the most [00:03:00] common scenario. So I’ll start with the good news, which is that in this scenario, the likelihood that someone who is complaining about trouble with their memory is suffering from a neurodegenerative disorder like Alzheimer’s is low.

And that’s because, in my experience, the vast majority of people who complain of memory troubles will end up having an entirely normal cognitive examination and workup. So one of the signature features of Alzheimer’s dementia, and many other forms as well, is that the person who’s affected by it typically has little to no awareness of a memory issue.

In the vast majority of cases, those who have a diagnosable case of Alzheimer’s end up in my clinic at the request of a family member or brought in by a family member. And oftentimes, the issue has become a source of conflict because the person with the memory trouble has no awareness of an [00:04:00] issue.

So that’s kind of purely an empirical observation , and it may seem like a paradox, right? If you’re noticing memory issues and the chances are it’s less likely to be something serious, seems a bit paradoxical, but so why might that be? Why is it that people with dementia are unaware of having a memory problem in most cases?

You might think that one reason would be that they just don’t remember that they’re having a memory problem. Right? And that may apply in some cases, but it typically isn’t the primary reason, at least in the earlier stages.

So in order for you to remember something, two main things have to happen. First you have to make the memory to begin with. You have to put it in your brain, and that process is called encoding. And then the second is you have to find it, right? You have to find where you put it. And that process is code is called retrieval. So you have encoding and retrieval, and those with Alzheimer’s commonly have trouble [00:05:00] encoding memory.

So one of the main challenges that our brain faces is in deciding what memories it should store. Even though the storage capacity of our brains is pretty mind boggling, we’re still dealing with a fixed amount of space and we have a fixed amount of resources that we can use. Storing memories requires synaptic remodeling and other structural alterations in the brain, and that takes energy and resources and we don’t wanna spend energy and resources on memories that we don’t need. So the vast majority of information that comes through our senses we shouldn’t be storing. So we need a mechanism for deciding what it is we should store, and the main mechanism that we have to decide what to store is attention.

So, our frontal lobe is intimately involved with, um, sustaining attention, and there are specific circuits in the base of the frontal lobe that [00:06:00] project to areas of cortex throughout the brain. And those projections, those connections are active when we are actively attending to something and they utilize acetylcholine as their neurotransmitter, so they’re referred to as cholinergic projections.

So when we are focusing intently on something, the frontal lobe is squirting out acetylcholine into those synapses that are active at that moment and based on our current understanding, what that’s doing is forming a kind of chemical tag. So it’s telling the brain that when you sleep tonight, you need to rewire such that this particular memory, which is associated with this particular pattern of activation, gets placed into long-term storage, through a process we refer to as consolidation.

So the gist here is that sustained attention is how we signal the brain to encode a memory into long-term storage. And then the neurotransmitter acetylcholine is an essential chemical in that process. And it’s [00:07:00] this encoding process that’s commonly impaired in Alzheimer’s disease. And the first class of medications that were developed for Alzheimer’s, and the ones that are still the most widely used are referred to, referred to as cholinesterase inhibitors.

And they work by blocking that, blocking the breakdown of acetylcholine so there’s more available in the synapses, as a way to try to boost this encoding process. Unfortunately it doesn’t work too well. We don’t get a lot of clinical benefit from it, but that’s the idea behind it.

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To subscribe, you can go to brainjo.academy/connection or click the link [00:08:00] in the podcast description. Alright, now back to the show.

So, as I said, to remember something, you have to first encode the memory, you have to make it in the first place, and then you have to be able to retrieve it or find it. And with Alzheimer’s, it’s the memory making process itself that is impaired, along with retrieval. So, though I can’t know it for sure, I imagine this experience of someone with Alzheimer’s is akin to kind of what we experience with our dreams at night. So, you know, every, every night you dream for an hour or so, and your visual cortex is busy creating all sorts of ridiculous imagery. And the vast majority of the time you’ll have no memory of it.

You won’t even have a memory that you generated it the next morning. And that’s because your encoding circuits are quiet.. But if someone could monitor your dreams and, you know, know what you were imagining every night, you know, they might remind you, Hey, remember that time [00:09:00] you were, you know, being chased by a banana?

And you’re like, that never happened. You would adamantly deny anything that you’d never encoded. And when you’re dreaming, you’re not encoding those images. So I imagine that that’s kind of what the experience of someone with alzheimer’s is like, if someone could read your mind and tell you what you’re dreaming each night, and you would adamantly deny that those things ever happened.

So back to our original question, which is, from people who are noticing that they are forgetting something, because this is a different scenario, right? This is when you’re noticing a memory issue, you’re realizing that there’s a memory there, you just can’t find it. So I know I was supposed to get something when I came into their kitchen, or I know I’ve met this person before and I should know their name.

So the issue is either incomplete encoding, so you weren’t paying close enough attention when you met that person, or you decide to go into the room or you’re not successfully retrieving it, so the brain just can’t find where it put it. And we experience this sort of thing a lot with the tip of the [00:10:00] tongue effect, right?

Where we’re trying to remember somebody’s name, or the name of something and we’re searching for it. We know we have it somewhere, we just can’t call it up right then.

So now we’ve established that those who are noticing, noticing forgetfulness enough to worry. Are unlikely to be in the early stages of Alzheimer’s.

What could the issue be? And of course it requires further unpacking because it can be many things. But the most common in my experience would be sleep issues and stress, stress and anxiety. So, as mentioned, the consolidation process of memory formation happens during sleep and during specific stages in sleep.

So, impairments in either quality or quantity of sleep commonly will lead to remembering less than you think you should. And then stress and anxiety can certainly do it, likely largely because of its effects on attention. You tend to attend to things less closely and be more [00:11:00] distractable in situations of anxiety and stress.

And relatedly, in some cases this can be a self amplifying process. So worrying itself about memory can then lead you to be more forgetful since worry and anxiety itself impair attention, which impairs memory. So you get into this vicious cycle, and in those instances, oftentimes me just telling someone that this wasn’t the sign of a more serious condition, that it may be largely fueled by anxiety was enough to make it much, much better.

The other issue could be just unrealistic expectations. So our brain is now receiving historically unprecedented amounts of information every day, and we’re engaging with that information in a much more superficial way. So we have more information coming at us and we’re more distracted than ever, so we’re pretty much guaranteed to feel like our memories are terrible in this particular information age.

So it’s unlikely to be the [00:12:00] early stages of Alzheimer’s or neurodegenerative process. However, I think it’s best to think of all of this, our memory function, as an evolution from normal function to decline to Alzheimer’s as a continuum rather than some binary either or process. Either there is an issue or there isn’t an issue.

And that means that it’s not until things have progressed to the point of impacting the encoding of memory, that it reaches the point of being clinically significant and meriting a diagnosis of Alzheimer’s. And so there will definitely be those who are in this category of noticing forgetfulness will have a normal examination who aren’t suffering from a neurodegenerative disease, but who are at a heightened risk relative to their peers. So where it may be a canary in the coal mine, so to speak, and a potentially very helpful one at that because you’re catching things at a stage at which there’s likely still a lot you can do to arrest and even reverse the process.

So remember, as we’ve talked about already, lifestyle environment and environment, not genetics are the [00:13:00] key driving factors here. And so I think the most important takeaway would be even if this doesn’t represent full on neurodegenerative illness, it would be a very good idea to still use it as motivation to address all of the lifestyle factors that we know are so important to the development of cognitive decline and dementia.

And it also includes specifically doing things that, that improve your memory, lifestyle factors as well. And I talked to some about that in the last issue of the Brainjo Connection Newsletter. So all in all, this is a complex issue. Still, the best way to fully analyze and characterize any cognitive complaints or deficits is with formal neuropsychological testing, which is typically a several hours long battery of, of testing that assesses different cognitive functions individually.

There are some online tools as well, which we may talk more about in later episodes. And ultimately, this issue of forgetfulness and memory [00:14:00] trouble is a very broad term, and so as always identifying the specific nature of it is key to figuring out its origins. So, that’s what I have to say about that. Dr. Wood, do you have anything else, any other questions or anything to add?

Tommy: Yeah, a couple of things that come to mind. The first is, I guess to reiterate some of the points that you made. And this is, these are points that you yourself have made that I read in your Brainjo Connection Newsletter myself, which relates to focused attention being required for memory encoding. And as we are wired for novelty, that’s what we tend to pay attention to. And so over decades of putting your car keys down every day, it’s not something that your brain feels, it needs to pay attention. Exactly. So it’s no longer novel or interesting.

So it’s not that you forgot, it’s maybe that your brain never thought it was important enough to really think about because you just do it every day. Right? And again, that’s sort of a [00:15:00] normal part of the repetitive nature of many of the things that we do that we’ve made then not be able to retrieve because we never thought they were interesting enough to encode.

Right. That was a helpful point for me to realize. Then, I’m thinking more about this sort of subjective period as I, as I think about the trajectory of cognitive function over the lifespan, before you get to frank dementia, you have mild cognitive impairment, which you could potentially diagnose depending on the test that you did.

And then before that you have this subjective cognitive impairment, which may be only you will notice because only you know what your baseline was. And using standardized tests is not always useful because it assumes everybody’s the same when they’re not. And this goes back to when we’ve talked about brain health before. What’s healthy for me or what I need my brain to do is different from what you need your brain to do.

So, I’m wondering like how we think about these subjective changes on this spectrum and you kind of said that already. So to broaden that out a little bit, something that[00:16:00] has become more popular and, and even almost ending up in formal medical literature is brain fog . You even mentioned it particularly around covid and, and long covid and things like that. So how does brain fog as in itself is a foggy term, but how would that fit into maybe subjective, like noticing your brain is not doing what you want it to do. Does this fit into that trajectory? How does it fit into other aspects? Like how would you approach that if, if a patient came to you with brain fog?

Josh: Yeah. Are you trying to trigger me by using the term brain fog ?

Tommy: I didn’t know. I didn’t know I could, but I’m glad that. It might get some interesting stuff.


So you’re right, the more non-specific we get with things and with terminology and whatever, the harder it is to pin down, the more things are subsumed by that umbrella. So, the issue you mentioned of subjective cognitive impairment, which is kind of considered kind of a preceding stage to mild cognitive impairment, which is a preceding stage to Alzheimer’s. And in that scenario, there will [00:17:00] be amongst people who have subjective cognitive impairment, right? I’m aware of some issue, there will be a subset of those who are noticing the early stages of something that could progress further. The challenge is that they’re the minority in terms of those who present clinically to us. And so that’s why I say the vast majority of those are not gonna turn out to be ones who are on that progression.

That’s not to mean it’s not something to pay attention to, it’s just to mean it’s not in that particular category. I have no idea what brain fog is.

I mean, I have a general nebulous sense, but one of the reasons that it is so ubiquitously used, is that it can mean anything. So it’s kind of like I’m having some trouble of some sort, but I don’t really know what to call it or what to say about it , which makes then saying what could it be caused from pretty much anything, right?

So obviously if someone comes to [00:18:00] me with that issue, I’m gonna do a detailed history and physical figure out what the specifics are that they’re noticing, if that’s possible. If it’s not possible, like I mentioned before in the realm of subjective cognitive impairment patients, stress and anxiety are huge and after any major life stressor, including covid 19, including prolonged hospitalization for anything, it’s not uncommon at all to have a period after that where you may feel like your cognition is not at its best because your brain is still kind of processing and overwhelmed by that entire experience, and that’s a normal phenomenon.

So, I think in the majority of instances, what people are describing is an attentional issue. I’m having trouble sustaining my attention on something for long periods of time, which can feel like I’m having trouble with attention, it can feel like I’m having trouble remembering things, it can feel like I’m having trouble multitasking. The problem with it being a term that’s used indiscriminately is it makes it difficult to provide a whole lot of specific [00:19:00] guidance on this is usually what the issue is or not.

But if I would say the most common would be what I’ve just described, as the main thing.

Tommy: Great. I think that’s helpful. I know that it’s a term that I hear frequently though I agree is not particularly helpful. I think some subset of individuals, or maybe that’s what they’re calling subjective cognitive impairment, that they’re on that trajectory.

If people feel that they’re not able to focus or remember, and they’re calling it brain fog, I still think that, like you said, it’s a nice reason, excuse to go over a bit of a checklist of the things that we know are important related to sleep and stress and maybe diet and maybe cognitive stimulus comes into effect as well. And, one thing that I think is helpful from some of the like chronic fatigue type literature is that people get into issues when [00:20:00] they, they’re in, they’re no longer capable of doing what they did before. And so what will happen is that when they feel good, they’ll do too much.

Mm-hmm. . And when they don’t feel good, they’ll do too little and actually, so sustained regular doses, as you recover from maybe a prolonged illness or something like that, even if it’s cognitive impairment that you feel that you have, making sure that you are continuing to build up in more of a progressive manner rather than the sort of the cyclical, boom and bust kind of approach, I think can be helpful to train yourself back up.

Josh: That’s a great point. I think that if we were to think about any type of traumatic event, whether it’s a prolonged illness or anything else, that there’s obviously sort of cognitive mental trauma associated with that as well. And just like we would allow a broken ankle time to heal and we wouldn’t put all our weight on it right off the bat, because it’s abstract and mental, we may not think of it in the same way, but it probably is analogous and at least approaching it in the same way is probably helpful. Thinking of there being [00:21:00] a recovery period where you’re sort of testing your limits and building up, but you’re not trying to go all in.

Once you feel that, that ankle’s a little bit, feeling like it can bear a little weight, you shouldn’t go full on right away. Same thing with our cognitive and mental faculties, and if we thought about those type of experiences having a period of sort of mental recovery on top of any physical recovery going through, I think that might help in sort of how we approach it and not overdoing it like you said.

All right, thank you again to Rose for that question and others who have submitted one like it. if you guys have any questions that come up as we were talking about this one or anything else related to Brain Health and Fitness, send them our way. You can click the link in the show notes or, head directly to brainjo.academy/questions.

That’s all for this episode and we will catch you guys next time. Thanks everybody. Bye-bye. Thanks so much for listening to Better Brain Fitness. If you’d like to support our efforts and help us [00:22:00] spread the word about this all important topic, you can share this podcast with someone else you think might like it, and you can leave a rating and review in iTunes, which helps others to discover it.

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