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We sit down with Roy Hamilton, a professor of neurology, psychiatry, and physical medicine and rehabilitation at the University of Pennsylvania. Roy shares insights from his research on using non-invasive brain stimulation to help individuals with cognitive problems caused by neurological disorders. We dive into common misconceptions about cognitive aging, explore proactive steps to maintain brain health, and discuss the strong connection between heart health and brain function.

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Roy Hamilton is a professor of neurology, psychiatry, and physical medicine and rehabilitation at the Perelman School of Medicine at the University of Pennsylvania. He is currently a trustee of the McKnight Brain Research Foundation, director of the Penn Laboratory for Cognition and Neural Stimulation, and director of the Penn Brain Science, Translation, Innovation, and Modulation Center.

He discusses the KevinMD article, “Working with your patients to promote healthy brain aging.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Roy Hamilton. He’s a professor of neurology, psychiatry, and physical medicine and rehabilitation at the Perelman School of Medicine at the University of Pennsylvania. Today’s KevinMD article is “Working with your patients to promote healthy brain aging.” Roy, welcome to the show.

Roy Hamilton: Thank you. It is really such a pleasure to be here.

Kevin Pho: All right, so tell us a little bit about your story and journey, then we’ll talk about the KevinMD article.

Roy Hamilton: Sure. So I’m a behavioral neurologist by practice, which means I see patients who have problems with memory, other aspects of their cognition. And just a little bit of background about my upbringing. So I was not raised in a medical family, in a medical background. My father, who was African-American, worked in a brewery, so he was a factory worker in a brewery. And my mother, at least initially, she’s a Japanese immigrant, still with us, and she initially worked out of the home, was a seamstress actually, working out of the home in addition to taking care of me, and then later on went back to school and eventually taught Japanese as a language. That’s after actually I was a little bit older. So medicine wasn’t in my background.

And I was a good student though. I ended up going to Harvard, and so I made the transition from Long Beach to Boston. One thing to note on the American side of my family, which was the only side of the family I had been exposed to with exception of my mother, on the American side of the family there wasn’t really a background of going to college. And so in addition to being the first person to pursue medicine, it’s also one of the first people on that side of family certainly to pursue any form of higher education.

So you can imagine coming from that background that there was some culture shock going from a working-class family in Long Beach, California to Harvard University. So that took a little adjustment to different lifestyles, different cultures. People were coming from different levels of what they were expecting to get out of life, and also snow.

And then from there, after acclimating to all of that, I stayed on for medical school at Harvard Medical School, and took a little detour, I went to MIT for a year, got a master’s degree in health sciences and technology. And then when it came time to look at residencies, fell in love with the University of Pennsylvania’s neurology residency, became convinced for a variety of reasons that it was the right fit for me, and so that’s where I landed, got my first choice, after spending a year of internship at home with UCLA to be a little closer to my family for that year. But then stayed on at the University of Pennsylvania for residency, fellowship, junior faculty, senior faculty, and here I am.

I should mention I’m a behavioral neurologist. The other thing I should mention is that I’ve got two other hats I wear. I do run a lab and a center that does non-invasive brain stimulation, so electrical and magnetic non-invasive stimulation of the brain, with the goal of trying to spur and remediate cognition in persons who have cognitive deficits on the basis of neurologic disease.

The other hat I wear is that I am the vice dean for inclusion, diversity, and equity for the Perelman School of Medicine. A lot of that has to do with the background I told you, that I came from a background where no one went into medicine. There were a lot of times when I was encountering things for the first time in my career development. So I’m pretty interested in making sure that other people who face that kind of uphill climb or lack of process knowledge have opportunities to really grow in the field of medicine and to make their careers as I’ve been fortunate enough to do.

Kevin Pho: All right, and your KevinMD article I think touches of course on your research. It’s titled “Working with your patients to promote healthy brain aging.” Tell us the events that led you to write this article, and for those who didn’t get a chance to read it, talk to us about the article itself.

Roy Hamilton: Sure. So I am lucky enough to have been approached by the McKnight Brain Research Foundation to help them with the mission of spreading the word about healthy cognition, and how healthy cognition can be something that individuals can take some degree of responsibility for, and take action, and how individuals can partner with their clinicians in order to try and optimize their cognitive health over, well, we like to call it over their brain span, but over the lifespan of their healthy brain, right?

And so it turns out this is a prevalent issue. It’s an issue that’s on the minds of people. If you poll them, as the MBRF has, close to 90 percent of people worry about what their cognition is going to be like in the future. But then if you ask them, to what extent do you think you can do things that have any influence over how your cognitive health is going to turn out over the course of your lifespan, by about a two to one margin people think that they can do something about their physical health from the neck down, right, more than they think that they can do anything about their cognitive health, about the health of their brain.

And so a big part of why I wrote that piece and why we’re talking today is to really help patients and help clinicians understand that they should partner with patients to really get a handle on the kinds of things that individuals can be doing in order to optimize their brain health throughout their lifespan, whether it be through their physical activity, their diet, their intellectual and social activity habits, the risk factors they should avoid, they should manage. There’s a family of things that we all can do.

And also to help people understand that while there are certainly disorders of cognition, neurological diseases of cognition, the brain does go through an arc of normal healthy aging that can manifest itself in certain changes in how cognition looks. And so one doesn’t have to interpret or become anxious that every single change in cognition that one observes is somehow the indicator of incipient neurologic disease, right?

And so helping people understand what they can do, and also helping people get a feel, and clinicians get a feel, for what the differences are between the healthy arc of human cognition versus red flags for neurologic diseases. I think those are the two points that I want to bring home in that piece.

Kevin Pho: All right, so tell us about some of the differences with the symptoms that may point more towards healthy aging versus a red flag. As you know, I’m a primary care physician, I do internal medicine. So when patients are telling me their story, what are some of the things that I should look out for in their story that would point more towards a neurological red flag versus something on a spectrum of healthy brain aging?

Roy Hamilton: Sure. So as we age it is normative, it is typical, to have some changes in our cognition. Let’s start there. And for those who have a hard time accepting that that is the case, let me just make a comparison to our physical health. It is fully possible for you to be a vibrant, fully active older person with respect to your physical health, but still to have different expectations of what your body could do compared to someone half or a third your age. You can hold those two realities in your mind at once.

So the kinds of things that you might observe is occasional forgetting. That is normal. If a person is occasionally forgetting a name or misplacing an object, the key features to look out for are acceleration in frequency and in severity, sort of the kind, category, and rate at which these kinds of errors are happening.

So if people are repeating themselves at increasingly frequent intervals, their stories or their questions, they’re immune to reminding, so individuals ask a question, they’re told the answer, and then the next time they’re asking the question it’s like the question was never asked. If people are becoming increasingly disoriented in what one might anticipate based on their history would be pretty familiar environments. And importantly, if these things show a trajectory of worsening over time, and worsening in degree.

Those are the kinds of things, and we can sort of go through many more, but those are the kinds of things that one would look for, with those two features of worsening over time. Those two features important.

Kevin Pho: So tell us about some of the things that we can do, say from a lifestyle standpoint, that can help us maintain healthy cognitive aging. What are some easy things patients can do?

Roy Hamilton: Sure. So I like to emphasize a few categories of activity, a few things that people should manage, and then a few things that people should avoid.

So the categories of activity are physical activity, right? We’re not living in some world of Cartesian dualism. It’s not like the brain is somehow completely separated from the body. That which affects the body affects the brain. So physical activity, intellectual activity.

And I’m going to pause here for a second, because I’m a neurologist, as we’ve discussed. A cardinal feature of brains is plasticity, neuroplasticity. It’s an important and key feature of how we learn and how we maintain memories and cognitive abilities. The brain perhaps more than any other organ is a use it or lose it organ, right? So maintaining intellectual activity.

One that people don’t often think about, social activity. It turns out that if you think about what brains do for us, right, a lot of the brain’s hardware, including a lot of the hardware I’m using right now to have this interaction with you, is dedicated to how we interact with other human beings. We’re social animals. So if you aren’t socially interacting, then you’re depriving the brain of some of its important activity.

Some things to make sure you’re managing, your sleep. There’s greater and greater evidence that sleep’s an important factor, an important restorative time for your brain, an important way for you to mitigate your risk of future decline. Your vascular risk factors if you have them, your diet.

And then I’ll focus on things that you should avoid. You should not smoke, and also you should really avoid excessive drinking. And so those are the things that I typically emphasize with my patients.

Kevin Pho: So when you talk about excessive drinking, how much would that be to be considered excessive?

Roy Hamilton: Yeah, that’s an interesting one. So if you go by the CDC’s definition, the CDC is going to call it 15 drinks a week for a man and seven drinks for a woman, or something like that, around those numbers.

However, it’s not that simple, and there’s more of a monotonic relationship between alcohol consumption and long-term effects on cognition. In other words, there is no regular dose that we think is OK, this dose is perfectly safe, and then you hit some kind of sigmoidal curve and all of a sudden like this dose is dangerous. It’s really that the more that you drink starting at zero, the more that you drink, the more likely you are to see deficits.

And so when I explain that to patients, I usually talk about it as, well, we make decisions around our desired quality of life, right? And so if you’re trying to make a decision around how much to drink versus its cognition, I try to explain, as far as we can tell, any amount introduces some degree of risk. The more drinking, the more risk. I try to minimize the amount in my lifestyle, and depending on the extent to which you want to be healthy in terms of your cognitive lifestyle, this is a controllable thing that you can minimize to the degree it’s important to you.

Kevin Pho: And when you talk about continued intellectual stimulation as one ages, is it doing Sudoku, crossword puzzles? What would be some examples of intellectual stimulation that people can maintain as they age?

Roy Hamilton: So usually when people give me examples and say, is this good or is this good, the answer I give is, well, yes, but to our knowledge there’s no single silver bullet. There’s no single magical cognitive activity.

The way I like to think about it and the way I like to describe it to patients is, it’s a little bit like maintaining a balanced diet, except with respect to what your mind takes in. You wouldn’t say, well, carrots are good for me and so therefore I’m just going to eat carrots, that’s my way of maintaining health. That would not be a reasonable way to pursue the notion of a well balanced physical diet or nutritional diet.

So I recommend that people take on a range of activities, guided by a few things. And I want some of them practical. They should be things that you think you might derive some degree of enjoyment out of, and that is practical, because it generally tends to be the case that people do not stick to habits that they do not like. But also that they should be at least of some mild cognitive challenge to you. I mean, if you can do them blindfolded with one arm tied behind your back, well then maybe it’s not actually cognitively stimulating to you.

So whether that be puzzles or games or new languages, new skills, new hobbies, a vibrant sort of reading habit, whatever that might be, that it be on some level stimulating to you rather than just something you could do passively. Which leads me to something of my pet peeve. I would say that most television probably doesn’t fall into that category.

One of my sort of soft rules is that if the activity keeps going even after your cognition has stopped, it’s probably not a useful activity. In other words, if you could sit in front of the television and you’re not thinking about it and you’re not attending to it, and it just keeps going no matter what, you can’t then walk away and say, well, I had my cognitive activity for the day, right? So those are some rules of thumb, but in general I encourage people to have a broad, varied, and wide palette when it comes to their cognitive activities.

Kevin Pho: One of the things that you mentioned earlier as part of your research, and you wrote about here, was the role of non-invasive brain stimulation when it comes to cognitive impairments due to neurological disorder. I’m actually not that familiar with this, so tell us a little bit about that, and how that modality can affect cognitive impairments from neurological disorders.

Roy Hamilton: Sure. So first let me introduce the modalities themselves, just take a quick, the one that I think maybe more clinicians are familiar with is transcranial magnetic stimulation, so TMS. That’s where you have an electromagnet, you’re going to place it against the skull, and it’s an electromagnet, so it’s inert when there’s no current running through it. When you run a huge amount of current through it over a tiny period of time, it creates a fluxing magnetic field, and that’s sufficient to cause underlying neurons to get stimulated to the point that they fire. That’s TMS.

And then the other tool we work with is transcranial electrical stimulation. So that in general involves placing electrodes on the head and running small amounts of current, on the order of milliamps, small amounts of current through them, where the idea is that the electricity is trying to get from point A to point B, between cathodes and anodes, and your brain is in between, right? And so it’s going to run through the brain.

And the idea behind using these technologies is that we think that we can influence plasticity in the brain, and we think that we can influence how specific circuits are engaged. So a lot of research in our lab at least right now is dedicated to individuals who have language problems, are acquiring language problems over the course of their lives, and to see whether or not we can spur the language system to be more active. However, there are others who are investigating other areas of cognitive health.

Now right now the main application of non-invasive brain stimulation in the clinical world is in psychiatric disorders, most specifically depression. And so a lot of the applications that I’m investigating and others in my field are investigating are just that, and they’re exploratory, they’re investigative in nature, they’re still research studies.

But we can see results where individuals who have cognitive deficits because of one neurologic disorder or another can show benefits. And because we think we’re helping to spur the brain into new patterns of activity, those benefits can stick for prolonged periods of time. It’s unlike, say, a pill, where once the pill’s out of your system that’s it. If we teach the brain, so to speak, to function in novel ways as a result of having been stimulated, we think that people can hold on to those changes over the course of time.

And one more thing I’ll add, which I think is relevant to the notion of maintaining cognitive health, because remember most of my research is in individuals who already have cognitive diseases, or I should say neurologic diseases with cognitive manifestations. But there is a literature that suggests that non-invasive brain stimulation can potentially be used to optimize and in some cases even enhance aspects of cognition in persons who don’t currently have cognitive complaints. It raises a number of interesting sort of ethical and social questions about what you’re going to do in a person who doesn’t have a complaint of cognitive deficits, but I think it’s an intriguing area to think about in the context of, as we all think about how we’re going to maintain our cognitive health over the course of our lifespan.

Kevin Pho: Now which specific neurological disorders are these non-invasive modalities being studied for?

Roy Hamilton: Well, I am interested in first of all many neurologic disorders, OK? So I’ll focus for that reason on the neurologic disorders that are of most interest to our work, broadly speaking, which is in what I’ll broadly call the neurorehabilitation space, which is why I’m a faculty member both in neurology but also, because I deal in cognition and rehabilitation, so neurology, psychiatry, and rehabilitation.

So our area of focus has historically been on aphasia, so loss of language ability in persons both after stroke. You may or may not know that aphasia is, we think, the most common focal cognitive deficit that individuals experience after a stroke. So depending on what survey or data you look at, maybe about a third of individuals who have a stroke will have some pretty significant communication disorder, and there are no other therapies other than behavioral therapies right now. So we’re trying to have targeted neural therapies.

But we’re also interested in persons who have degenerative disease, persons who are losing language ability because of neurologic disorders of aging. And so that family of disorders is referred to as primary progressive aphasia. So that’s an area of investigation.

But that’s our work. Others are looking at whether or not stimulation of the brain can help with memory in individuals who are experiencing memory disorders, including persons with mild cognitive impairment and Alzheimer’s disease. Stimulation of individuals who have executive function disorders, either because they have deficits of frontal executive function, or because they have deficits in other domains of their brain but we think that by ramping up their frontal lobes they can sort of control their cognition better. And so there’s just a variety of ways in which this is being explored in neurologic disorders of cognition, to help remediate cognition.

Kevin Pho: It’s very exciting. We’re talking to Roy Hamilton. He’s a professor of neurology, psychiatry, and physical medicine and rehabilitation at the Perelman School of Medicine at the University of Pennsylvania. Today’s KevinMD article is “Working with your patients to promote healthy brain aging.” Roy, let’s end with some of your take-home messages that you want to leave with the KevinMD audience.

Roy Hamilton: Sure. So I want to return to this idea of clinicians partnering with patients in order to help them take action to preserve their cognition. As clinicians we’re all pretty familiar with the notion of preventative health. We know how to really reinforce that physically in our patient population, and I think it’s really incumbent on clinicians to also reinforce that with respect to leading a healthy cognitive lifestyle.

And the last thing I’ll point out is, I started out by saying I’ve had the good fortune of having a partnership with the McKnight Brain Research Foundation around this topic. If you’re interested in this topic and learning more and sharing more with your patients, I’d encourage you to check out our BrainWorks Optimize Your Brain Span campaign. Our website around that for your patients is mcknightbrain.org/brainworks.

Kevin Pho: Roy, thank you so much for sharing your expertise, perspective and insight, and thanks again for coming on the show.

Roy Hamilton: Thank you. It’s a real pleasure.