Alvaro Pascual-Leone MD, PhD - Brain Health & Cognitive Fitness

Announcer (00:06):

You are connected and you are listening to specifically for seniors, the podcast for those in the Remember When Generation. Today's podcast is available everywhere you listen to podcasts and with video at specifically for seniors YouTube channel. Now, here's your host, Dr. Larry Barsh

Larry (00:40):

Specifically for seniors, is privileged to be able to share with the listeners of this podcast a year long series of podcasts that parallel activities that actively support cognitive fitness for the residents of Orchard Cove, a Hebrew senior Life residence in Canton, Massachusetts. Stay tuned at the end of this podcast for more information. It gives me a great deal of pleasure to introduce Dr. Alvaro Pascual-Leone, medical Director of Hebrew Senior Life's Woke Center for Memory Health and co-author of the Guide to Cognitive Fitness. Dr. Pascual-Leone is a professor of neurology at Harvard Medical School and sees patients as a cognitive neurologist. His main focus of research is brain health. Across the lifespan, Dr. Pascual-Leone established and directs the Sydney Bear Junior Fellowship in clinical neurosciences. He has authored more than 750 scientific papers, several books, and is listed as an inventor on several patents. Dr. Pascual-Leone has been recognized by Thompson Reuters as one of the world's top 15 neuroscientists and one of the world's most influential scientific minds. Welcome to, specifically for seniors Alvaro. It is indeed an honor to talk with you.

Alvaro Pascual-Leone (02:29):

Thank you so very much, Larry. It's my pleasure to be here. I appreciate the opportunity.

Larry (02:37):

Let's start talking about you. What got you interested in studying brain health a lifespan duration?

Alvaro Pascual-Leone (02:47):

It's a good question. I, I've always been interested in the, from, from youth on, I was interested in the question of what makes humans behave humanely, what makes us who we are as a, as an individual and as a, as a race? And and so that led me to neuroscience because I wanted to understand not just the description of it, but but rather the fundamental building blocks of the biology of it. And, and when you start looking at brain as the, as the substrate of who we are and what we feel and what we ambition for our future and what purpose in life we develop, when you start looking at the brain, you can then go solely in quotes into disease and try to deal with when things go wrong, what can we do about it? But you come soon to realize that if we want to really promote health, we need to sustain the healthy functioning of that organ, of that brain.

Alvaro Pascual-Leone (03:53):

And, and we know relatively little in neurology or in neurosciences as to what is an appropriately healthy brain as we live a longer life, and what can each one of us do to sustain it. And so that led me to, to explore that and to become interested in that. And I believe in a sense in, in neurology, we've made enormous advances in, in diagnosing a problem, in identifying a problem, in treating a disease. But we still have to learn a lot and, and improve on how to prevent the disease to begin with, how to promote brain health so that one stays healthy rather than one has to try to recover.

Larry (04:42):

Is there an obligatory decline in our cognitive abilities as we age?

Alvaro Pascual-Leone (04:49):

Yeah, that's a wonderful question. The short answer is no. There, there isn't. There are things that with age will become better at, and there are things that we do lose abilities on. So, so it depends a lot on what specific functions, abilities we talk about. But the notion that the sum of all those abilities should be going down as we age is by no means a consequence or an obligatory consequence of aging. Instead, when that happens, it, it points to the fact that there must be something off, some illness, some dysfunction. I think of it as something similar to what happens as we become older and from childhood on. There's certain abilities we have that we become less able to do. I used to be a pretty good soccer player. I still know what I would do, but my body doesn't seem to quite get me there in time.

Alvaro Pascual-Leone (05:56):

I used to love to drive a tricycle and at some point I, I, I outgrew the tricycle and I couldn't get myself bent to, to be inside the tricycle. And it's not that I lost abilities. I, I gain others and I outgrew the tricycle and love bicycles and, and and so I think what we've come to learn is that with cognitive functions is something similar. There are some abilities that we do lose capacity on as we get older, but others we get better at. And a consequence of that getting better at is that with age, we get a richer representation and capture of the world that surrounds us of the, of the distant relationships between things. We have more knowledge, more vocabulary. And with that, arguably our brain, if it's healthy, evolves in the substrate of more wisdom. And, and society needs that wisdom of the elders. And, and, and one of the challenges that, that my own work has tried to to address is how can we benefit from the fact we're living longer? Overcoming the challenge that comes with the fact that as we live longer, there's also more chances to develop illnesses. And if, if we allowed it to happen, then those illnesses rob us from the potential benefit of older age groups sort of enriching society.

Larry (07:32):

In your book, the Guide to Cognitive Fitness, you introduce the concept of cognitive reserve. What is that?

Alvaro Pascual-Leone (07:43):

So a cognitive reserve refers to a capacity of the brain and ability of the brain to tap onto resources and, and in a sense, put in another gear. That means is that our brain is not like, it's not using all its cells and all its connections. It, they, they're all being used, but just like a car can shift into another gear and in doing so, revolutionize the motor in a different way. And it allows us to accelerate suddenly. So the brain also can tap onto resources that allow it to cope with unexpected challenges, with illness, with you know, stressors, for example. If we have a bad night of sleep if we travel transatlantically, if we have an infection and up other by things. With all those circumstances, what is coming to them is that our brain is called to cope with the additional burden of, of those insults of those challenges.

Alvaro Pascual-Leone (08:58):

And our brain has the capacity in the form of reserve to do so concretely in this setting of an illness in the brain, our brain has the capacity to tap onto that reserve so that the disease doesn't manifest, the symptoms don't manifest. And so early on when we discovered these notions of reserve, it was in the context of finding that people would pass away and in autopsy, in their pathology analysis, after that, they were found to have had Alzheimer's disease in the brain, but they had never shown any signs of loss of cognitive ability or dementia in life. And so the notion was put forward that perhaps some individuals had the ability to resist, to cope with the pathology and maintain function. That's the notion behind reserve. And we all have that reserve, and we know there are certain things that make it moral less likely to have a lot of it. The main one is education. When one starts engaging in education early on, has the appropriate social cultural background and continues to have a, a way to challenge one's brain as we live longer. And that promotes cognitive reserve, that promotes that <affirmative>. The exciting good news is that we all have the ability to keep building on it

Larry (10:35):

So it it carries on through the lifetime.

Alvaro Pascual-Leone (10:39):

It does. So it is not the case as we at some point thought that one gets the amount of reserves that one gets, and that's what you got for the rest of your life. But rather, like much about the brain we're coming to learn, there is the capacity to build on it, to get more of it and the risk because of the same flexible changes that take place in the brain of potentially losing some of that capacity.

Larry (11:10):

So all of this basis of co cognition depends on a healthy brain. Now, his impossible task. Can you describe the functioning of the human brain, how it works in two minutes, <laugh>

Alvaro Pascual-Leone (11:27):

In two minutes <laugh>?

Alvaro Pascual-Leone (11:29):

Well, so the way I think about it is this. So we know since the Spanish neuroscientist, we know that the brain is made out of very sophisticated specialized cells called neurons. Those individual neurons bind together, work together in, in ensembles of neurons, and it is those ensembles, those teams of neurons that actually allow us to do every single thing we do. So everything a human is able to do, every thought, every feeling, every expectation, every behavior, every single one of them is supported by an ensemble of neurons. And those ensembles of neurons are the building blocks of human behavior. So a a a healthy brain is one that has well-functioning en symbols to support all the behaviors, thoughts, and emotions that each individual wants and desires

Larry (12:47):

As we age, what happens to our brain? What's, what's normal in aging and what isn't?

Alvaro Pascual-Leone (12:59):

So expanding from that vision of these ensembles of neurons, connected neurons in the type of connections between neurons change as we age the connections that are to neighbors very close by become less and less effective, whereas the connections between more distant relatives, as it were, it become richer. What that translates to is that the ability to very quickly learn that this is a cup and is black, sort of rather arbitrary, but neighboring attributes becomes weaker. We're slower, it did because we have less resources to do it. But the ability to relate that cup to something that happened when my wife and I first went to displays, those sort of more distant associations, more, more relational things become actually greater with, with age. So there are changes with age that are expected in the type of connections that exist between brain cells and those changes are normal and become the substrate of the things that we become better at and also the things we become less good at as as we age.

Larry (14:33):

So I'm getting from all of this that the old cliche, you can't teach an old dog new tricks, really isn't true.

Alvaro Pascual-Leone (14:44):

It's not true. It it is not true. And, and, and it's not true. And, and it's remarkable to me that people have known this, you know, if if we ask ourself, if we look at my grandfather, your grandfather, the, the, the older people we know, they were able to learn new stuff, right? They, they, they, they were acquiring skills and yet established neurology and neuroscience kept telling us, no, no, no, no, no, no. There is a level of of functioning and after a certain age you just go downhill. There's nothing we can do. And you could see people surround you going, it's not true. It's not the case. Yeah. And, and so I think now finally, the, the signs has caught up with what popular knowledge sort of knew and has come to realize. There is a substrate, there is a foundation why we all have still the ability to learn and acquire skills. And there is a risk and a challenge to that, that is associated with age, but is not due to age. And it has to do with the fact that the longer you live, the higher the risk of developing illnesses, therefore the more important the things we can do to prevent illness and to sustain health.

Larry (16:03):

Can you be specific about the illnesses that may affect brain health?

Alvaro Pascual-Leone (16:09):

Yeah, there are many. There are many, and they, they affect us, so they can affect us across the H span. So there are forms of infections that can damage the brain. There are different inflammations how to immune illnesses where the body becomes its own enemy. There are tumors including forms of cancer that can affect the brain. And then there is this whole bag of what we call neurodegenerative diseases. Diseases where the brain almost in a perverse kind of way is, is programmed to lose specific cells or specific connections too early. Where there is the, the, the program genetically programmed brain death of specific structures. That includes things like Parkinson's disease, it includes things like Alzheimer's disease. And finally, because the brain depends on blood supply, there is the whole risk of insufficient blood supply to specific parts of the brain, which can cause strokes. It can cause bleeds in the brain because of abnormal blood supply, and it can damage lead to the death of brain cells, which can finally also happen if one, despite the rather sturdy protection that the brain sits in inside the skull, if one has an accident and sustains a brain injury because of the trauma. So, so there's traumatic brain injury, ischemic or vascular brain injury, the whole bag of neurodegenerative disorders, then infections, inflammations, cancer.

Larry (18:02):

So one of the problems with older adults is falling, and that is a risk to brain health.

Alvaro Pascual-Leone (18:10):

You got it. That's exactly right. It's, it's an interesting conundrum because the risk of falling can lead to brain injury because of the risk of healing your head and damaging the brain inside the skull. But it's also the case that lack of brain health problems of functioning of the brain increase the risk of falling. So it becomes almost a catch 22, a vicious cycle. There are, there are illnesses that make us more prone to fall, which in turn if we fall, increase the risk significantly of sustaining injury, including of the brain.

Larry (18:55):

I think one of the most feared medical problems as we age is dementia. Dementia takes many forms. Can you describe them a little bit?

Alvaro Pascual-Leone (19:13):

Yeah. So if you ask the people in the us but also in, in other countries, those studies have been done in Europe and, and elsewhere. The number one feared condition, more so than cancer and cardiac disease combined, is dementia, is the loss of oneself. You know, I think I've heard it from many people, loved ones and patients alike. As long as I continue to be me, as long as I continue to be myself, I will be I'll be okay even if I have pain, even if I have illness. That is the biggest fear. Neurologists describe dementia as three things that have to come together. The first one is, one has to have a progressive loss of more than one cognitive function. So let me unpack that. So it has to be getting worse, and it has to affect not just memory or not just my ability to find words or to express them or my attention to details of my capacity of orientation.

Alvaro Pascual-Leone (20:33):

It has to affect more than one such thing, and it has to be getting worse. And finally, the third thing is that it has to impact my ability to do things in day-to-day life. So it has to have a functional impact when all those three, three things are present, we call that dementia to be explicit. That means dementia is not the same as Alzheimer's disease. Oftentimes people say, oh, he has Alzheimer's disease, but what they really mean is he has dementia. And Alzheimer's disease is one cause the more, most frequent cause, but just one cause of dementia. But it's important to know that not everybody with Alzheimer's disease develops dementia. Some people have the capacity in their brain to hold it off and, and have the disease, but they don't manifest the symptoms. And it's also true that not everybody with dementia has Alzheimer's disease. They can have dementia for other reasons, for other causes.

Larry (21:46):

So what you're saying is just because we forget names or don't know where we put the car keys doesn't mean we have dementia.

Alvaro Pascual-Leone (21:57):

It's exaggerate. It does not. And in fact, in some of those things are normal with aging the way. So, so for example, not, not being as quick at finding the names of people, that is not a sign of even bad brain health. That's something that can happen with age. I, I think of it in a sort of sort of maybe facetious way, but if you allow me a teasing way I I think one can think, well, if I, as I get older, I know what I want, I know what's important with me. For me, increasingly and frankly, remembering your name is not that relevant. You know what I mean? Right. So, so there, our brain evolutionary evolves to, to figure out what is important is I relate to you well, and that we have a connection, and that we feel this is valuable time and that people listening get something from it, whether malva or John, is that really critical?

Alvaro Pascual-Leone (23:03):

It is not that critical if we achieve the other. And so you can look at some of the abilities that we now know happen to get lost with age as, as having a deeper sense perhaps of, of, of what is really meaningful. So if, if it's the names that are lost, it's not a problem. If it's the whole sense of what we're trying to achieve, if it's the relationship, the ability to relate to others. If I can't remember what the heck we were here for now that's a different realm, that's a different problem. But in any case, one such problem to your point, is not sufficient to call it dementia, is it would not be a dementia.

Larry (23:50):

I guess the most important question now, and one that I suppose most listeners will be thinking is, what can I do about my brain health at this stage in my life? In your guide to cognitive fitness, you stress that having a sense of purpose is one of the most impactful factors in slowing down the onset of symptoms of dementia. We'll be covering this more detail and future podcasts, but can you explain a bit more about this?

Alvaro Pascual-Leone (24:29):

Yeah, thank you for that. So, so if you allow me, if this, perhaps the most important message that we've learned about brain health is that it's never too late to start focusing on it. It's never too late with age. Any age, yes, better if we start early, but never too late to start making a difference, to still make a difference. Whether your brain is healthy now or you have an illness never too late, you can still promote the health of the rest of your brain, the one not affected by the illness. It's still valuable. So that's the single most important thing. The second thing is, as you point out, what are the things that each one of us can do concretely? Then there it turns out the list is long. There are many things, but there are some things that are particularly critical from what we're learning.

Alvaro Pascual-Leone (25:25):

And the two most important things is not feeling lonely. So having a sense of support, a relationship. Human brain is a machine to relate to others. We are social beings. We're not planned and conceived to live in isolation. We are defined by the relationship with others. And with that, if people answer the question, I feel lonely, not, I live alone, not, I'm alone. I feel lonely. If they feel lonely, that undermines the brain health. And the second important, most important factor is, as you were saying, the the fact that our brain is an organ. We as beings are individuals who are projected, are defined by a goal. Goal, has to do with others, cannot have to do with me to connect the two topics, but it has to be something that transcends me, is beneficial for others, but drives me forward. That's purpose in life, broadly speaking.

Alvaro Pascual-Leone (26:31):

And oftentimes as we get older, we feel more isolated, we feel more lonely. The recent pandemic has illustrated this for many of us. And, and in addition to that, we start feeling, it's tempting to feel I just should prepare myself to pass to die <laugh>. There is nothing more for me to do. And, and both of those things are very dangerous from a brain health perspective. And they, and they, they end up costing us joy and wellbeing and fulfilling life for the time we have. So it's not about extending life is, is is filling with purpose and with meaning and with life, the years of life we may have. And in order to address that social relationship and maintaining a purpose in life ends up being the most important things. And any one of us can actually accomplish that and define that and work towards that. And it's never too late.

Larry (27:39):

Okay. There, that's two of what you call and you work pillars of cognitive fitness. What are the other four?

Alvaro Pascual-Leone (27:47):

Yeah, so the others are a physical activity. We are you know, oftentimes not as physically active as we need to be. It's in fact for the brain, we know that physical activity is critical, literally to make new neurons, something that we call neurogenesis. Our brain is still making neurons throughout life and, and that that among many other things is something promoted by physical activity. So physical activity is important not just for overall health, but for brain health. In addition to that, physical activity by promoting overall health helps with brain health. So there is a lot of benefit to be derived by being and remaining physically active. That's number one. Number two, the same way that physical activity is important, cognitive activity is important, and to be specific, challenging the brain to continue to learn new stuff. So let me unpack that for a second.

Alvaro Pascual-Leone (28:57):

It, it's not about continuing to do what one enjoys and already does. Well, that's, that's great. That's, that's joyful and all power to people who want to do that. But that's not the recipe to maintain brain health, to maintain brain health. You wanna be enjoying the things you do, but you also want to be challenging your brain to do more, to do new, to do other stuff. It's the same as in physical activity. If I already am an amazingly fast runner by amazingly fast running, I'm not getting better at my physical conditioning. So the same way that we need to push ourselves physically, we need to push ourselves cognitively. And so cognitive challenges is the other pillar. In order for those two things to take place, we need good nutrition, which is another pillar of, of brain health. And it's not that there are specific things one should eat or can eat that are magical, magically going to get my brain in good shape.

Alvaro Pascual-Leone (30:03):

Rather, it is about not eating too much and eating the right mix of things. A Mediterranean diet actually, the kind of food that I grew up eating was fortunate growing up in the course of, of, of the Miran in Spain. So no butter, oil, a lot of greens, a lot of vegetables, a lot of fruits, relatively less red meat, a lot of fish comparatively. That actually ends up being the best balanced diet. And and as I say, combined with it is the fact that overall, overall in general, at least, we tend to eat as much as we can to not keep gaining weight, and we should instead eat as little as we can to not lose too much weight. So it is, we, we eat too much. So, but food nutrition is the other one. And the final fourth one is sleep. It turns out that our brain needs rest, needs sleep, not just to recover and feel rested, but because sleep itself plays a crucial role in organizing and shaping the connections in the brain there is remodeling, cleanup, jobs, cleanup work that takes place in the brain during sleep.

Alvaro Pascual-Leone (31:30):

And if we don't sleep enough, that doesn't take place. And if it doesn't take place, then it impacts both our cognitive ability and our risk of developing illness. It undermines our brain health.

Larry (31:46):

For the people who are gonna be following this series of podcasts, it probably would be a good idea for them to pick up a copy of your book, the Guide to Cognitive Fitness. Where is it available?

Alvaro Pascual-Leone (32:01):

Well, I'm a little biased there. I think it's great <laugh>, but I think it's a, it is a useful little guide. It's a, it is a short, I think, accessible guide of wellbeing that is published by Harvard medical press and publications. It can be gotten from them as a, as a booklet can be ordered from them. Book can make information available. And and I think the, the staff of, of Harvard publications did a wonderful job curating and ensuring that the information is valuable and, and quite practical. Which, which I had the, and had the pressure of sort of serving as the, as the editor for that. Yeah.

Larry (32:46):

Is there anywhere else that people can get more information like the Walk Center or the H s L website or, or a way to test their own cognitive function?

Alvaro Pascual-Leone (32:59):

Yeah, so I am a big believer that oftentimes we shy away from getting our brain checked when in fact we should, let me explain. So most of us have, have come to realize the value of going yearly for a wellness exam for a yearly checkup to our doctor. And as part of that, we do some assessments for prevention early detection of cancer and cardiac disease and so forth. Super, super important. But even though Medicare has, has pointed out the importance of doing the same for the brain, the fact is that that generally doesn't happen. There's many, many reasons for it. Among others, primary care physicians are pressed for time. The tools that they have available to do an appropriate assessment of the brain are not optimized. It takes too long. There are many reasons, but the bottom line is that generally people bring up brain or cognitive concerns only after they are present and have been present for a long time.

Alvaro Pascual-Leone (34:17):

On average, it's about 10 years too late, 10 years after it has already led to a disease. So to your point, if we all had a checkup of our brain when we're healthy to make sure that everything is okay to get the guidance of what to do, that would be extremely valuable, I think for any one of us, even if a problem is identified, because if it's identified, it is identified early and then we can do more about it. So the work center is one such place where one can go and get that type of assessment. That's why we settled on the name Work Center for Memory Health, emphasizing the health, it's not, it's not about taking care of you when you have an illness that we do too. I think we do very well, but, but we want to make sure that we promote the health. And, and so I think to talk with one's primary care physician about the possibility of having a checkup for the brain, a little assessment that might highlight, identify potential problems and things one should do to promote brain health would be valuable for everybody. And and if they want, we would be of course delighted to, to do that type of all through the work center for, for anyone.

Larry (35:43):

Are there any places around the country like that?

Alvaro Pascual-Leone (35:47):

There are, there are a bunch of places around that are and, and more developing. I think one of the concerns that I often have is that while there are very good places doing it, Mayo Clinic, Cleveland Clinic have pro programs on brain health where they're doing similar things. There is also a lot of places developing where, where what they do is not quite as carefully thought out, <laugh> and, and, and so there is a little bit of a risk of of selling almost snake oil to, to, to people where you say, oh, everything is okay because look, this, these colorful pictures show that everything's okay. That that is not often and not always sufficient or, or, or careful and critical enough. So, so it's important to know which places, but, but the, the point, it's, we're not alone. There other, many other places where this is done and done very, very well.

Larry (36:57):

Is there anything we missed? Anything else we should cover on this podcast?

Alvaro Pascual-Leone (37:05):

I, I mean, I think just, just completing the thought of what you were sharing Larry and asking me I would, I would suggest to, to any one of us that if you have concerns, if you worry about your brain function and your brain health and wellbeing, cognitive abilities, we call that subjective, cognitive concerns. So it's, there is a diagnosis even for it, and it turns out that holding onto that worry is really not a good idea for, for brain health purposes. So if you worry, you should get assessed, you should get a checkup of your brain because we can identify the problem, we can tell you everything is okay. If everything is okay, we can help you define what to focus on. And and at the very least, we have a clear, clean baseline to then compare as, as years go on and, and make sure that things stay well and stay steady.

Alvaro Pascual-Leone (38:18):

You know, we used to think that when people worry they should just quote, get over it. It's not a big deal. You're okay. But it turns out that about 50%, 60% of people who have subjective concerns develop over the course of the subsequent few years into a path that leads to dementia. So it's, it's a serious thing to, to act on rather than try to, to brush it to the side. And, and perhaps a a, a concrete action suggestion for people would be, if you worry, don't hold onto that worry. Be evaluated, find out, and, and for everybody, whether you worry or not, to think about what can you do, what can every one of us do to promote brain health by addressing and engaging in more health promoting lifestyles along those six pillars that we've talked about, purpose in life, social relations, physical activity, cognitive training, diet and sleep, that, that would be, I think, my, my sort of recommendation overarching, because engaging in those things would lead to thinking more, being more aware of, of the things that promote brain health. And that alone ends up promoting a sense of ownership and a sense of optimism, both of which are extremely important to promote brain health.

Larry (39:53):

Alvaro, thank you so much for coming on the podcast. This has been so valuable and will be for our listeners.

Alvaro Pascual-Leone (40:02):

My pleasure. Thank you for having me.

Larry (40:06):

Over the coming year specifically for seniors will be hosting a series of six podcasts each based on one of the six pillars of cognitive health that Dr. Pasqua Leoni briefly covered in today's podcast, will be joined by a series of experts and co-hosts so that you at home, wherever you live, will be able to benefit from the knowledge and exercises presented as much as the residents of Orchard Cove. This is an exciting addition to our regular guests and topics of interest for older adults and a series of events you do not want to miss. We are currently investigating the possibility of bringing these to you in a way that will allow you to ask questions to the participants during the podcast. But since we have not finalized the schedule for when these podcasts will be available, we wanna be able to notify you when they are scheduled. The only way, the only way we can do that is if you sign up for email announcements at www.specificallyforseniors.com. You certainly do not wanna miss a single episode on cognitive health. We look forward to having you join us on the path to cognitive fitness. It's your brain, it's up to you to take care of that. Stay connected.

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