Can improving heart health help protect our memory and other thinking abilities as we age?

Welcome everyone to our Tea with the Experts webinar. Just going to give a bit of time as we slowly see everybody come online. Right well thank you so much everyone for joining us for our Heart Health Club Tea with the Experts webinar. It's so so nice to have you here and we are so incredibly excited as I have such a good one for you today. We've had so many of you sign up which is absolutely fantastic. So clearly you guys are interested in this topic. So I'm really really glad that we can deliver. So my name is Jenny. I am the Communications and Corporate Partnership Manager at Heart Research Australia and today we're joined by our Heart Health Club Clinical Neuropsychologist Dr. Miranda Sainz. Miranda is a Clinical Neuropsychologist with a special interest in the role that modifiable lifestyle factors have on physical and mental health. She's a keen advocate for the physical and mental benefits of mindfulness and meditation as well as the importance of challenging oneself and pushing beyond one's comfort zones. And one of the things I admire so much about Dr. Sainz is that in addition to recommending this to her patients this is genuinely something that she lives and breathes in her personal life and including recently completing her first marathon. Very impressive. So I really want to thank everybody so much for all of your interest in this webinar and for so many of the questions that you all sent in. It's been really really helpful for us to see the thoughts that you've got and the topics that you're interested in for us to be able to structure this webinar so that it's of interest to you and covering the topics that you you're interested in. Please just bear in mind this is an incredibly broad topic and it's something that Dr. Sainz and I can talk about for hours and we have many many a time so please be mindful that we're only just scratching the surface here. The focus of this particular webinar is preventative health and the role that heart health plays in brain health and dementia and how lifestyle factors can play a protective role. If you have any questions relating to this or any of the topics we're talking about you can post them in the Q&A box at the bottom of the screen which we've got down there and we'll get to those at the end. But please be mindful that we're unable to comment on individual cases or circumstances because there is so much background history and so much information that's required when discussing individual cases and this isn't the correct forum for that to be able to get that full medical history. So please if you have concerns or questions they're absolutely valid so please take the time to book an appointment with your health professional to ask those questions because it's just really really important that you have some clarity on those but sadly we can't we can't get to that today. So we also won't be discussing medication or any surgical management apart to this. This webinar is being recorded so if you want to re-watch it or share it with someone else or you have to pop out in the middle of it that's absolutely fine. We'll be sending a recording to everybody later this week. So Miranda welcome. Thank you. Thank you so much for joining us. It's just it's amazing to have you here. We've been chatting a lot about this topic so I'm really grateful to have you here to be able to to share your knowledge with all of our Heart Health Club members. Thank you. So one of the things that we discuss a lot at Heart Research Australia and with you is cardiologist Dr. Eddie Barron's forum. So he talks about these forums as simple steps for a healthy heart so that meals, movement, measurement and mental wellness. You are very kindly our Heart Health Club medical advisor for mental wellness and you and I have had so many incredible conversations about the importance of these forums and how relevant they are not just for heart health but also for brain health which was actually a topic that was quite new to me before I reached out to you and spoke with you. And you also talk about how the two work together. Can you just give our audience just a bit of an idea as to why this area is of such interest to you and why it's a topic that we as a charity focused on cardiovascular disease need to be talking about it? Yeah sure that'd be great. So I couldn't count the number of times I've had a patient sat in front of me in my clinic room and maybe that patient's just had a diagnosis of dementia or maybe they found out they've got a genetic risk factor which makes them at a higher chance of getting dementia. And after I guess a shock has worn off the patient will sit off opposite me and without doubt almost every patient says to me, okay I've got it, I've got the gene or I've got dementia, what can I do? Is there anything I can do to even potentially minimize my chance of developing symptoms or potentially slowing symptom progression? And it's really good to be able to give patients some concrete things that they can do on a day-to-day basis that can potentially delay the onset of dementia or slow the progression over time. So this is what we're talking about preventative health care. And something that surprises me a lot of people don't realize how intimately connected the heart and the brain are. So I just want the general public or the listeners today to have a better understanding of how they're connected and potentially things that they can do to make their brain as healthy as they can. Before we do go any further though I just want to clarify a couple of terms. So dementia is a term that a lot of my patients and a lot of people in the general public use synonymously with Alzheimer's disease. But they're different terms. So dementia is not a condition, it's an umbrella term for a number of different conditions. So there's lots of different types of dementia. Dementia itself means in essence a condition where there is progressive cognitive decline over time. So cognition goes progressively downhill. Alzheimer's disease is the most common type of dementia and vascular dementia is another very common type. As I said there's loads of other types but today I just want to focus primarily on Alzheimer's and vascular dementia. Right that's so interesting because I actually didn't even know that there was a difference between the two. Yeah yeah well most people don't. So another term that is relevant now I'm sure some of my listeners will be familiar with this it's MCI. So M for mild, C for cognitive and I for impairment. Mild cognitive impairment MCI. So MCI maybe some of the patients or people listening today you might have been told that they have MCI. MCI is a it's not a diagnosis it's a label and the reason I say that's a difference it's describing a person a patient who is experiencing mild cognitive changes but it's not enough to significantly impact their functioning. So what that might be is a patient may have some memory problems but they can still do their job by using lists or by taking a bit longer to do tasks. They can still function but they are noticing changes and ideally you can see those changes on testing. That is MCI. The relevance of MCI is MCI has got a high chance of developing into dementia but MCI can be caused by different things. For example a mood disorder can cause changes of cognition but if you treat the mood disorder the cognition can improve. So MCI can represent different pathologies or different things so it can get worse it can get better. In some cases MCI actually just stays plateaus essentially for years. And the third concept I just want to introduce is the fact that so dementia is diagnosed on the basis of the onset of clinical symptoms so cognitive symptoms that impact your functioning. But before you get these symptoms research has shown there's years even sometimes more than a decade of the development of pathology or damage in the brain slowly slowly slowly over time. So it can start as I said more than a decade before you start showing symptoms and it gets to a point where the brain cannot tolerate that damage anymore that the symptoms emerge. And the reason I'm raising this is most people don't know that and also it's relevant in terms of some other stuff I'm going to say later. So I just wanted to start with this. Get some of the definitions out of the way. For someone who doesn't have a Can you break down or can you explain to us in sort of simple terms how the heart and the brain are connected? So why are we having this conversation? How are the two connected? Yeah sure I used the term an intimate connection before and I like that term because it shows it's actually a two-way connection. For simplicity because we're limited with time today I'm going to focus on the impact of the heart on the brain not the brain on the heart. So we all know that the heart's role is to pump blood to the body and the brain's included in that. And the brain is reliant on a constant flow of blood. Now interestingly the brain only weighs about two percent of our body weight but it uses 20 percent of our body's blood. So you could say it's a very very thirsty organ and it needs constant blood supply. So I'm not going to make you guess how many brain cells there are but maybe the listeners can have a think to themselves if you had to have a guess. Guess in your mind how many brain cells you think there are. There's approximately 86 billion brain cells. Okay I wouldn't have guessed that. And each of those brain cells needs blood supply, constant blood supply. So what the heart's pumping blood to the brain and what the blood does for the cells is it gives the cells nutrients and oxygen to function. Importantly it also helps to remove waste and toxins from the cell and it also helps with an immune response. So that might be for example if you have an infection in the brain it can help with the immune response. So I've got my model brain here. So if the brain would go that way, if that were my head, and what happens the blood, I've also got a heart here as well, so the blood comes up from the heart through the aorta and it goes up towards the brain and what happens is quite a big vessel to start with and then it narrows as it splits and it splits and splits and branches off and branches off into smaller and thinner and thinner vessels so that blood is able to reach all the different neurons. And you can see here, this is just obviously an example, but you can see the very thin blood vessels and if I open my brain up, remove my cerebellum and one of the lobes here, you can see all the vessels. Internally there's a lot of vessels as well. So the heart is pumping blood to reach all the cells in the brain. Now I just want to add, if the brain cells go without blood for a period of time, they die and that's very important to understand as well. Yeah, but also I suppose if the blood is also removing the waste as you were talking about, if it doesn't sort of effectively do that properly, I can assume that would cause a lot of issues as well. Yeah, 100%. So if blood flow is restricted, not enough blood, or if it's stopped completely. So we've studied all of the questions, all of the wonderful questions that you've all sent through. Unfortunately we can't get to all of them, but a lot of the ones that have come in have been around heart disease conditions and in particular atrial fibrillation. Can you explain how conditions like atrial fibrillation can contribute to cognitive impairment or dementia? Yeah, sure. So atrial fibrillation, I'll call it AF because I always stumble on the word fibrillation. So I'll just call it AF for ease. So for people who don't know AF or don't have AF, AF is a type of heart condition, a type of arrhythmia. So it's the most common type of arrhythmia and essentially the heart beats abnormally, often too fast. And what this can result in is erratic, so chaotic blood flow. And when the blood flow is too slow or stagnant, you can get the formation of a clot. Now in theory that clot could travel out of the heart anywhere and often the AF related clots are quite big. So if that clot then travels up towards the brain, it travels as I showed you up through the vessel and then the vessels split and branch out. And so it will go up one vessel wherever it goes until the point that it, the vessels get more and more narrow until the point that it can't get through any further. And what you then get is complete occlusion or blocking of that vessel so blood's not flowing. And so any neurons beyond that point are not getting blood. And you remember what I said, if a neuron doesn't get blood, it will die after an amount of time. So you have an area of cell death, which is what we would call a stroke. So when AF is poorly managed, you're at a higher risk of having a stroke. If I just grab my brain again quickly just to explain. So the different parts of the brain are responsible for different functions. The front part, the frontal lobe, I'm sure most people have heard of, is involved in higher level thinking, so planning, organising. You've got a part of the brain that's responsible for generating language. You've got a part of the brain that's dedicated to recognising human faces. So it's very, very specific. One part for the movement of the right hand, one part for the sensation of the left leg. So depending where the stroke is will depend on the symptoms, but very often you experience cognitive impairment following a stroke. And unfortunately, because the clots are quite big, often the blockage is at a lower point, so you're going to have a larger stroke. So that's how it can affect cognition in that sense. And in terms of what causes AF, so age is a significant factor as genetics has got some component as well, but it's worth noting that other vascular risk factors increase your chance of getting AF. So high blood pressure, diabetes type 2, these things can increase your chance of getting AF. And the reason I'm highlighting this is lifestyle factors that we'll talk about later can reduce your chance of having high blood pressure or type 2 diabetes and hence reduce your chance of developing AF. And on the flip side, if you do have AF, the best management, so there's surgical and medical management options which I won't discuss, but there are also lifestyle factors, so exercise, diet, stress management that help manage it to reduce your chance of complications. And finally, one thing I'd just add in terms of Eddie Barron's M for measurement, monitoring your AF and having a close relationship with your doctor to ensure that it's best managed is very important. Yeah and I think that's why we love the 4Ms so much because it's such a great framework because the more conversations I have with different experts in against each of the M's, so much of it is interlinked and measurement is just is so crucial with so many different aspects. You know one of the things that we talk about with measurement is the importance of just knowing your numbers, so cholesterol, blood pressure, blood sugar levels and so on and these can be done you know through your heart health check at your GP, you can get health checks done at the pharmacy just as an initial point of contact, but it's just we say it's so important to know this so that way if you are taking steps like exercise or doing positive things, you can see the improvement on these numbers so it gives you a way to track it, but it also gives you a baseline so if something happens and suddenly you get an increased figure, you can then put plans in place immediately to work on that. So how important would you say it is to knowing these numbers relevant to cardiovascular risk factors that you would get through a heart health check? So for instance do things like knowing our cholesterol levels in particular, does cholesterol have a role in the development of cognitive impairment or dementia? Yeah so in terms of your first question, one of the key take-home messages for today that I want people to leave with is to know your numbers, to have regular contact with your GP, your pharmacy where you can get your measurements done, do not be scared, it's good to know them and if they're out of whack, the good thing is there's stuff you can do about it, it's not like you find they're bad and there's nothing you can do, you can easily address these issues if they're out of whack, so please don't be scared, please regularly monitor them and the second part with reference to cholesterol, so cholesterol, when I say cholesterol, most of us have heard the term which is currently often used, good cholesterol, bad cholesterol. I always get confused which one's which. Yeah, said bad cholesterol in reference to LDL cholesterol, I'm not going to go into detail now because we don't have the time but when I refer to cholesterol that's what I'm talking about. If you have high levels of cholesterol which is largely impacted by diet and also lack of exercise can contribute and you have high levels of cholesterol that's poorly managed, so you're not managing it properly, it can lead to a process which is called atherosclerosis. So I don't know if people have heard of atherosclerosis but it's a process that can happen in the blood vessels and so the blood vessels, if we just use this for example, so the blood vessels are like a straw and they're meant to be quite elastic and atherosclerosis is a process by which you develop these little plaques around the inside wall of the vessel, little fatty deposits and what it does is it makes the vessel stiff, they call it a furry, they say is it furry I think, furry arteries, so it makes it stiff so it's not so easy for it to get bigger and smaller and also makes it more narrow because it's got the plaques. So what this can do in terms of the heart, it can restrict blood flow to the heart if it's in the coronary arteries and that can lead to angina or heart attack and it can also, if a plaque ruptures, it can cause a blood clot which can also cause a heart attack. Now in terms of the brain, you get the same process in different vessels so if you get atherosclerosis in the vessels going to the brain, the vessels at the base of the brain are wider than the coronary arteries which are very narrow but you can still have a plaque rupturing and causing a blood clot and heading up into the brain and causing a stroke as I spoke about before which can lead to cognitive symptoms. But a slightly different process, high cholesterol, so if you've got high levels chronically of cholesterol, it can contribute to a condition called small vessel disease. Probably some of our listeners have heard that term, another term for it would be small vessel ischemic disease and small vessel disease refers to damage within the tiny vessels in the brain. So some of the small vessels you saw and also deep within the brain, you can have damage from cholesterol to the tiny vessels. Interestingly, other things that can contribute to small vessel disease are diabetes and high blood pressure. Again, I'm raising that point in terms of how often the vascular risk factors interlink. So having some small vessel disease is not uncommon in older life. So often a patient will have a brain scan and they'll see some evidence of small vessel disease. It's not inevitable with aging but it's not uncommon. But if you get too much small vessel disease, if it gets moderate or severe, that's when you can start experiencing some cognitive symptoms from the small vessel disease. So it accumulates slowly, it's different from a stroke, it happens slowly over time but that can lead to vascular dementia but it can also bring on the symptoms of Alzheimer's sooner. So Alzheimer's is a different pathology, it's a different disease process. But remember at the beginning I talked about the pathology developing for years and years until the brain can't tolerate it anymore. If you have this small vessel disease, it makes the brain, I guess you could say weaker, so it can't compensate for the Alzheimer's changes and so the patient would show symptoms more early. So yeah, I guess cholesterol, high cholesterol can affect the brain a number of different ways and lead to cognitive symptoms in a number of different ways as well. But again, just hammering back the point that it can be well managed. So knowing the numbers and management are critical here. And I think small vessel disease from conversations I've had with other people is actually quite difficult to diagnose so it's even more important to really, really know your numbers and keep track of that. And when you talk about the bad cholesterol, do you also have the same response if it's hereditary? Because I know there's a lot of genetic confinement with bad cholesterol. Do you have the same response? The same response in the sense of? So just the cholesterol, the cholesterol that does the negative thing, does it work the same way if it's caused by diet or if it's caused by genetics? So family history? Yeah, so there are certainly some conditions and as part of, like genetic conditions that cause high cholesterol. Yeah. So what I'm talking about is. The diet related one. Yeah, which has also got a smaller genetic component but really I'm focusing on the high cholesterol where it's a mixture of diet, sedentary lifestyle, genetics and age. So there's protective things that we can do to avoid that. Apologies for the background noise. I think a truck has just driven past and my dog has been a little bit upset about that. So apologies if anybody else is going to hear that. It's either barking or snoring with him. So either way, if that's what everybody hears, it's my dog. So you mentioned briefly diabetes. So that was actually also something else that came out a lot in the question. So whether there's a link between diabetes and dementia? Yeah, sure. So diabetes is also a bit of an umbrella term like dementia. Essentially it refers to the body's conditions, different conditions that result in the body's inability to produce insulin or to use insulin efficiently or maybe a bit of both. So the two I want to distinguish between and often people refer to this as the same thing but they're very different conditions, is types 1 and 2. So type 1 diabetes is an autoimmune condition. It's relatively rare compared to type 2, about 5% to 10% of cases. And that's the diabetes that is often diagnosed in childhood or early adulthood and the patient can't produce insulin. So the patient has to administer insulin for their survival. Without insulin they won't survive. So they have to have daily administration of insulin. Type 2 is more common, so around 90% of cases and tends to emerge in later adulthood and is often a combination between not producing enough insulin and the body not being able to use the insulin well. Risk factors are age and genetics. There's a genetic component but no surprise, high cholesterol, high blood pressure increase your risk of developing type 2 diabetes. Also lifelong poor dietary habits, so eating a diet too high in sugar, unhealthy fats and a sedentary diet. Very much so. That's the funny thing, all this information, it always comes down to those four M's, especially measurement. That's why I love them so much, yeah. So I want to focus on type 2 diabetes and with type 2 diabetes the goal is that we all have a healthy sugar range that our blood sugar should be in. If it drops too low in type 2 diabetes it's hypoglycemia, if it goes higher it's hyperglycemia. Neither is good for your cognition but I want to focus on hyperglycemia when the blood sugars are too high. So I'm talking about poorly controlled type 2 diabetes, not just type 2 diabetes but poorly controlled. So if someone's not taking medication they've been administered, not monitoring their blood sugar levels, not following a good diet etc. So if you have high levels of blood sugar, hyperglycemia, a lot of the time it can be quite toxic for the body. So it can damage the kidneys, it can cause diabetic retinopathy in the eyes, it can cause problems to the heart, so atherosclerosis, remember I said it's a contributor towards that, it can cause blood clotting, so a heart attack. But moving to the brain, poorly controlled diabetes, hyperglycemia, has multiple negative impacts on the brain when it's long term. So it can lead to shrinkage of certain areas. One area in particular is the hippocampus, which is an area that's critical to memory and Alzheimer's disease. You can see inflammation in the brain and it can damage the blood vessels so lead to strokes. The other interesting thing research has shown quite recently is the presence of too much sugar in the blood on the brain, it can accelerate the accumulation of two of the Alzheimer's markers. So I'll just break that down, there's two markers in the brain, often before the disease pathology that I said increases before the clinical symptoms start, associated with Alzheimer's called amyloid and TAP. And if you have high levels of blood sugar for a long time, it can accelerate the accumulation of these in the brain, which then can bring on the onset of Alzheimer's symptoms earlier. So I do see patients come in and they really don't look after their type 2 diabetes well enough and so I really hope another take home message is the importance of managing type 2 diabetes and it is very manageable. Just touching very quickly on type 3 diabetes, which is referred to in the media and by scientists, it's not actually a formally recognised medical term but it comes from a connection that they've found between type 2 diabetes and Alzheimer's disease, both having insulin resistance as a key feature of the pathology. So I'm not going to go deeper into that one because that's going off on a bit of a tangent. Just thought I'd touch on that one, just thought I'd touch on that one. Yeah, yeah, yeah, no that's so interesting and I think one of the other challenges we're having at the moment is this increased cost of living. I recently watched a webinar in terms of the increased cost of living and the impact on our healthcare and what you were talking about in terms of the importance of managing your conditions is so vital in terms of protection for moving forward. One of the other things I was saying is concerns that they're having is that people are being prescribed medication and aren't taking it because they're trying to keep the cost down but the long-term effect of not doing that is clearly so much more costly. So it's just so vital that you have, as you were saying before, regular appointments with your pharmacy or your GP in terms of being on top of those numbers and having those health checks really, really vital. So thanks for kind of covering that up again and reinforcing that point because it's so important. One of the other questions that came in a lot was around family members and whether dementia is genetic. So you've obviously been talking in terms of all of these sort of lifestyle risk factors and protective things that we can do. If you already have a predisposition from genetics or what have you, how important is it to I guess even more so know these numbers or is there anything different you can do? Yeah, so just in terms of genetics, I obviously get a lot of those questions as well. So there's a few rare subtypes of dementia that have a heavy genetic component. So one of those is familial Alzheimer's disease and typically we'll see a line of dementia down the family. So you'll see maybe the mother, the aunt, the sister, the grandmother and going back. And often onset of the genetic dementia is even a few decades earlier on average, say 30s, 40s, 50s. Recently or in recent years, they have identified genetic markers that can increase your likelihood. So it's not a definite but it does increase your likelihood. So yes, I would say if you are aware that you are a carrier of one of these genes or these mutations, sure, you might be more vigilant to this advice. But the truth is in any case, aside from autosomal dominant genetic cases, lifestyle does play a huge role in mitigating when you will develop symptoms. So I would say to everyone and I myself practice what I preach. Yeah, absolutely. You do. And I think all of us, I mean, there must be genes we're not aware of that exist, that increase our chance. We're just not aware of them. I may be a carrier, you may be a carrier. We don't know. But the best thing we can do is all do the best we can day to day to reduce our risk. Yeah. You and I are both incredibly passionate about preventative health. And one of the statistics that we share quite often is that eight in 10 cases of premature heart disease and stroke are preventable through healthy lifestyle behaviours and focusing on these modifiable risk factors like you've been talking about. When we keep saying modifiable risk factors, what do you deem as modifiable risk factors and why is it important to understand them? Yeah, so I mean, we've touched already on a number of them. Modifiable risk factor is something that puts you at a lower or a higher chance of getting a disease and modifiable means you've got some control over it. So what we might think of as fixed, for want of a better word, risk factor might be age. As much as we want to, we can't all get younger. And genetics. And I will just harp in there saying how important it is to know your family history. So if you have got older relatives who are alive, ask them. So I'm talking grandparents, parents, aunts and uncles, cousins. Ask them what conditions they have and just make a note of it. It can be really helpful to know. Yeah, absolutely. With the modifiable lifestyle factors, they are things that we know that we can do to improve our health. And most of us have heard this information before. Exercising is good for us. Avoiding sugar is good for us. We know, a lot of us know what is good for us. But there's often something in the way of people actually taking steps to make that change. And that's where we need to be breaking, I guess, breaking that habit and making people actually take that next step. Yeah, absolutely. But can you, so say we're one of your patients, can you talk about some of the practical things that we could do in reducing our risk of developing dementia in particular? Yeah, sure, sure, sure. So we've talked a lot about the preventative stuff, so managing risk factors. I also think about things in a way of promoting brain health. So if we park the preventative stuff for a second, and I want to talk about two concepts. So one is neuroplasticity. And I know neuroplasticity is increasingly used outside of the health field. So maybe some of the listeners will know about neuroplasticity. And the other one I think is a little bit less known as cognitive reserve. So just to explain what neuroplasticity is to start with, neuroplasticity is a concept. So previously, people used to think that the brain, you're born as a baby, and the brain grows and grows and grows. And there's accelerated growth during adolescence. And then come, you know, maybe early, mid-twenties, the brain stops growing, it's fixed. And over time, it starts to decline. So I might use the length of my arm as an example. When I was born, it was this long, and it grew and grew and grew. And I've reached a certain point, and my arm's not going to get any longer. Doesn't matter what I do. It is as long as it's going to be. Or height, maybe is a better example, because at an age, you do start, a lot of people start shrinking. But recently, what in recent, certainly recent couple of decades, they've better understood that the brain is not fixed. The brain actually responds and adapts to the environment until the day we die. So if you think about, for example, my arms, imagine I woke up one morning, and for some crazy reason, I decided, I'm just going to use my right arm from now on for everything. My left arm's redundant. I'm disowning it. It's just going to hang here. And this is where it's all at, right? So I'm going to write with it, I'm going to eat with it, I'm going to brush my hair with it, I'm going to go to the gym and work it out. We all know what's going to happen. My right arm is going to become really, really strong, stronger than it is now. Bigger, stronger, more powerful, more coordinated too. And my left arm, my poor left arm that I've neglected, is going to shrink. My muscles are going to atrophy. It's going to just hang limply, with no muscles, no tone, and become redundant. So it's the use it or lose it principle. So that's like a really graphic way of describing the brain. So the brain responds to the environment, and there's two ways in which it responds. And remember, this is until the day we die. The brain has the capacity to grow new brain cells, and it's also got the capacity to rewire itself, so to make connections between brain cells. Every time you learn a new skill, you're making new connections, and every time you practice that skill, the connection gets stronger. So my son's learning piano, for example, and when he first started, that was a new connection forming, which I explained to him, that's why it's so hard. And the more he practices, the connection's getting stronger. So you can hear if he plays the same song, getting easier, it feels easier, but that's not just a coincidence. That's the brain rewiring. Now he's a kid, but if you learn piano, it would get easier too. That's not just magic, that is the brain rewiring itself to learn a skill. And this process also comes into play if you have damage to the brain. So if you have a stroke, there is some natural recovery after a stroke of neuronal rewiring. So it's important to keep that in mind. There's a really interesting study that was a hallmark study in the concept of neuroplasticity called the London Taxi Driver Study. I don't know if people have heard of it, but back in 2000, they decided to get a cohort of London taxi drivers. So back in the day before Sat Nav, any taxi driver in London had to take a test called the knowledge. And what they'd have to do, they'd have to study a map of all the intricate roads throughout London. So London's a big place, and if anyone's been, the big roads are easy, but off all the big roads, all these little historic, tiny windy roads, the driver would have to learn that. So when they pick up a passenger, the passenger says, I want to go here, and the driver can just drive there without having to look at the road map. So they have to pass it and they get their licence. So what they did, they got the taxi drivers and they scanned their brains and they found that taxi drivers who'd passed the knowledge and were working had larger areas within the hippocampus that's responsible for spatial navigation. But the interesting thing is, the more years the taxi driver had worked as a taxi driver, the larger that area of the brain. So this was concrete evidence that honing in on a skill can even increase structure that's responsible for that skill. So I thought that was really relevant. Yeah, yeah, super interesting. I thought that explains your passion for constantly challenging yourself and trying new things. Yeah, a hundred percent. Yeah, yeah, I like taking that, I'm loving that. So now switching to cognitive reserve, I like to think of cognitive reserve as a life spent taking advantage of neuroplasticity. So the premise of cognitive reserve is it's a brain's capacity to withstand damage. If you've got a higher cognitive reserve, you can withstand more damage before you show symptoms from pathology. Does that make sense? So what leads to cognitive reserve is a lifetime of emotional, social, intellectual engagement. Every time you've studied a course, tried to learn a language, done a dance class, studied whatever, it's helped build those connections, build those connections which makes the brain stronger. Then you add pathology to that and you start seeing pathology in the brain, but the brain is very strong. And so a strong brain with a high level of cognitive reserve can either use a different route to do the same task through the brain, different network, or maybe it functions better through the impairment than a brain with less cognitive reserve. And the relevance of this is we can do things now and ongoing to boost our cognitive reserve. So it's a lifetime, you know, we can't change the past, but we can continue to strengthen the brain so if and when we do get pathology, we've got a better chance to be able to withstand that pathology. Right, so it's that protective type thing. Very much so. So would you say, Renee Brown often talks about the benefits of play. One of the things she says, which I love, is she says rest and play is as important for us as diet and exercise. Would you say that, and play she defines as doing something sort of purposeless that isn't sort of driven by a particular result at the end of it. Would you say that play component helps build up that cognitive reserve? Yeah, I think very much so. And I think it very much leads into a topic that you and I have spoken a lot about. About being busy versus being engaged in meaningful, joyful activities. I think that plays into that. Yeah, absolutely. You know, we seem to have created this life of being so busy and having so much on and in some cases there almost seems to be a bit of a badge of honour of being busy. And you know, you and I talk about this a lot. So how do we differentiate between being busy versus living a mentally engaged life? Like there are a lot of things that we can do, like we can enjoy exercise and going for a run or doing this or catching up with friends, but it almost becomes when you have so much on, it almost becomes more of a stress because you've got so many different things on. How do you kind of differentiate that? Excellent question. So let me talk about a patient that I see. When I say a patient, this is a fictitious patient based on so many patients I've seen. Someone rocks up and they say, oh, I'm having problems at work with my memory or my concentration, I can't multitask, I'm having word finding problems, whatever their complaint is. And I say, okay, take a step back, tell me about a typical day for you. Well, the alarm goes at 5.30 and before I get up, I quickly check to see if the team in America has emailed me about this deal that we're closing. And I see they have, so I quickly respond to that. But then I remember the kids have got netball before school, so scramble out of bed, grab the netball stuff, make their lunch, grab the kids, forget the family stuff, jump in the car, get to work, blah, blah, blah, blah, come back, more of the same, fall into bed, and then repeat and repeat and repeat and repeat. So that, I would say, is a consequence of the modern living. That, to me, is busy. And is that person stimulated? Yeah, that person's brain is very stimulated. That person's brain is overstimulated and the brain does not like to be overstimulated. So I'm sure a lot of us here will relate, listening will relate to this, but when we're overstimulated, we're more inclined to perform more poorly on a task and research has certainly shown that. We're likely to have mental fatigue and stress and even be on autopilot. So just say you are that woman that I told you about, she's doing a task or she's signed up for a course, she'll go to the course and be sat there and listening, but her engagement's at 70%, not 100%. Yeah, 100%. But already, she's less engaged despite being busy. Now, interestingly, if you are stressed, stress obviously has an impact on your body, but if you say, if I say to that patient, out of 10 right now, how stressed are you? Actually, we could ask people listening. If you had to rate right now, how stressed are you? Out of 10. You'd have the whole range from zero to 10, but it's very subjective. So there are ways of measuring stress objectively and that's taking a measure of cortisol in the body. So cortisol is one of the stress hormones. So studies have shown when cortisol levels are risen, the higher, that people perform more poorly in cognitive testing, which is not surprising. What concerns me more is when cortisol is high, is too high for too long, so sustained cortisol. Little spikes in cortisol are very normal and it's actually, cortisol can be very helpful for us. We need cortisol, we need at least some level of cortisol and it can help us perform better, respond quickly. But if you have it chronically high, like my patient, it can be very bad for the body and the heart and the brain. So long-term, higher levels of cortisol can decrease neuroplasticity and in particular, in the hippocampus, there's a lot of receptors that are sensitive to cortisol. So you can even see shrinkage in the hippocampus if someone is chronically stressed with high levels of cortisol. And remember I mentioned hippocampus is critical to memory and to disease. And I guess just finishing off the topic of cortisol, this woman I talk about, my fictitious patient, and I see this in my personal life with a lot of people in modern living, people have this heightened level of stress, they get used to it and that becomes their new norm. So it feels normal. So if I say to that person, what's your stress? They might even say zero, one, two, I'm fine, I'm totally fine because they've become numb to the bodily sensations of stress. And so they go about their life with peaks but their baseline is high and that is really dangerous. That's so common now, so common. Yeah, so common. So now leading from that, an engaged life, I would say an engaged life is striking a balance between being present in a meaningful activity, what I call a neurologically nourishing activity, but also having breaks so the brain can recover and grow. So recover and grow neuroplasticity. So when I talk about neurologically nourishing, I'm talking about, if you think about your own life for people who are listening, neurologically nourishing, we're thinking something that might be new or might stretch you a little bit, a bit challenging, keep it varied. Don't just do the same task day in, day out, even if it's hard, keep it varied, so mix it up. But it's got to be meaningful and it's got to be joyful for you. There's no point doing something that's challenging that you hate. Yeah, because you're not going to want to do it, there's no motivation to do it. And the breaks give a chance for our brain to recover, so the neurotransmitters recover and cortisol drops, blood pressure drops and when you take a break, you have the chance for your brain to process what you've learned. That's another thing, if someone comes to this webinar, which is amazing, you're learning information, if you then went straight into another activity, you're not giving yourself a break. If you stop, even if you stop to listen to music, on some level, your brain is processing, consolidating this information and that's where you see increased growth in the brain. Yeah, great. So breaks are critical. Yeah, we've got a really great question from one of our participants which aligns with this. She's saying, we know stress is bad for the heart, so what are some tips for relieving stress? So if you were working with a patient, what is an example that you might practically work with a patient who is struggling with this in terms of helping them relieve stress or give this balance and vice versa, how do they get more meaningful connections? Yeah, wonderful, wonderful question. So I might use that patient as an example, so it's concrete. So with this patient, the first step I would do is education. So what we're doing now, I think people only make changes when they can understand the why, why it's important. The second issue is understanding how someone ended up in this situation. So part of it's situational. If you're a parent, you're working, you've got young kids, realistically, you have a duty, you've got responsibilities, you can't just get rid of one of those responsibilities. But there's also often unhelpful beliefs behind, underneath, deep down. So for example, people might feel like being busy means that they are efficient. Having breaks means I'm lazy. Having breaks means I'm being selfish. And so I like to break down to what really is driving this person. Some people keep very busy to avoid facing their reality, because they're scared to maybe something happened in the past, or maybe there's a situation in their current that they're trying to avoid, so they keep really busy. So there's no point just saying, oh, reduce what you're doing. You need to understand what's stopping someone and address that first. Then I would work with that patient on scheduling breaks, and ensure that they're disciplined not just to get on their phone and scroll through Facebook, but actually take a meaningful break. So whether that's a mindfulness meditation, or a walk through nature, all of these things, even a five minute walk through nature. So research shows that being in nature, gentle exercise, gentle movements, and engaging the senses physiologically can reduce cortisol. So I myself will take regular breaks when I'm working. I'm lucky to work in a hospital where we just back onto this beautiful, I guess it's a river, a very large river, so it kind of smells like the ocean. So I go down there for five minutes, and I sit in the sunshine, and I smell the ocean smell, I listen to the birds in the water, and I just zen out for five minutes, and I can physically feel the cortisol release, or reduce, and then I go back refreshed. So it's about being dedicated to taking those little moments, and I would say people who are so busy, they're very in their brains, and they've become numb to their body, so I would say engaging your senses is very important. Yeah, and I think one of the things that you often say, which I love, is sometimes it is quite difficult to be able to go for a walk in nature when you've got work, you've got meetings back to back, then you've got to run and pick up the kids, or what have you, or the grandchildren, or whatever. But even things like, you've said to me before, that even just eating your lunch, or noticing whether there's a crunch, what you're tasting, what you're smelling, what's going on around you, rather than just sitting there scrolling through your phone, or typing out emails while you're eating, stop, and just be mindful with what you're doing, as you were saying before, just be present. I will just add the other end of the extreme is a patient who maybe is not working because they're retired, or maybe they can't work because of a diagnosis, and they come in, and I say, what do you do during your day, or your week? And they say, oh, I don't know, maybe I pop to the shops, I go for a walk. I'm like, well, there's a lot of hours in the day, how do you feel the rest of your time? Oh, I potter at home. And when you potter, what do you mean? Oh, I watch a bit of telly. What do you watch on telly? Oh, whatever's on. So this person, maybe they wash the dishes, they're not doing nothing, they are doing stuff, but that's not neurological nourishment. So with these patients, what I do, and I don't know if there's people at home listening who might relate to this a bit, I get a piece of paper and make it into seven days, and I say to the patient, try and schedule at least one session of neuro nourishment per day, and make it at a certain time, so maybe 10 o'clock on a Monday, and I talk to them about neuro nourishment activities, so physical, mental, social, whatever. But coming back to what you were saying before about the joy, I spend time with my patients, because often people are so removed from who they are and what they love, so I spend time with my patients talking about their values and what excites them. And one patient I had, who's got early dementia, early stage dementia, he's got arthritis in both his knees because he used to be an athlete, but his values and joys are being active, being outdoors, being in nature, being around people, so he's now started doing water aerobics two times a week, and he's met a couple of friends, and they go for a coffee afterwards. So 10 o'clock Tuesday and Friday, water aerobics, coffee with friends, that's those two things. Perfect, social connection, everything. Just joint and men's shed as well, so I strongly encourage everyone to have at least consciously decide to have one session of neuro nourishment per day, and you're ticking that box. I'm really going to have time, we have four minutes left to the meeting finishing, so I just want to have one last question for you. If there was one take-home message that you could pass on to our supporters today, what would it be? Okay, definitely thinking preventative. Please be aware of your numbers, and be proactive to manage your risk factors. Thinking of promotion, promoting brain health. Choose, make a commitment to doing even one neuro nourishing session per week. Beautiful, love it. And finally, I just have to add, if you have got dementia, and you've listened, good on you for coming, and if you're feeling in a rut, if you're feeling stuck, if you're feeling like life is not joyful and meaningful, please, please, please speak to your GP, speak to your psychologist, because there can still be meaning and joy in dementia. 100%. Oh, that's a beautiful, that's a beautiful final message. Thank you so much, Miranda. I'm so incredibly grateful to have had you here. You are just such a delight to speak with every time, and I've been so excited to, you've got so much incredible knowledge, we could chat with you for hours, but we're literally maxed out the minutes we've got, so thank you so much, everybody, for coming along. As I mentioned, we have recorded this, so keep an eye on your inbox, and you'll have the recording of this by the end of the week, and have a lovely day, everyone. Get out there and have some nourishing mental time, take your break, and I hope that everybody's found this interesting and learned something, and Miranda, thank you so much. You're an absolute gem, and we're so grateful. Thank you for having me. See you. Thank you, bye. Thank you, bye.