Column: The aging brain: Navigating the gray zone

by Jennifer Werely

The line between neurological changes related to normal aging and what constitutes a degenerative neurological condition grays, creating a zone of uncertainty.

The goal, as a neurologist, is to make this distinction black and white, eliminating the gray zone. This can be challenging, and generally the impact weighs heavily on the family as well as the patient. What are normal changes associated with aging and when should symptoms prompt a neurological evaluation?

Mr B. was a 73-year-old account executive who shuffled into the exam room and sat down, slouched in a chair. His face stared blankly and he was reluctant to engage in conversation. I asked him to tell me about himself, where he was from, his upbringing and his family to better understand his experience. This brought vigor into his slouched posture and vitality into his expressionless face. Listening to his story helped me understand his journey. His wife filled in the gaps and clarified their concerns for which he lacked insight. He needed her there for support; I needed her there for guidance.

After a comprehensive history was obtained, we proceeded to the neurological examination. This was the turning point. The exam allowed me to identify objective abnormalities guiding us out of the gray zone ”“ why his walking had slowed, he had fallen frequently and had difficulty eating with a spoon due to his tremor. He began understanding his family”™s concerns and we discussed options available to ease his symptoms, give him back some independence and rekindle the confidence he once knew.

The gray zone of uncertainty ”” is it normal aging or is it the disease process? ”” is commonly where the family lives. It is a scary place in which one can both fear the worst and hope for the best, where one vacillates between thinking something is normal for aging versus having an undiagnosed underlying medical condition.

Often patients lack insight into their disease, but families generally sense when something is just “not right.” It is a family member who often alerts me to subtle changes in their loved one”™s cognition or behavior. Likewise, it is the family who often can assess if my treatment plan is effective.

Neurological conditions associated with aging include memory changes such as dementia, movement disorders such as Parkinson”™s disease, stroke, headache, seizures, pain syndromes, spinal issues and nerve and muscle disease. Each of these conditions has associated treatment options designed to optimize overall functionality. The nature in which each condition affects a person”™s ability to perceive or interact with their environment is variable. The burden often falls on family to provide support.

What is “normal aging” when it comes to brain function? It would be considered normal to have a mild decline in the ability to learn new things or retrieve information. Although attention, learning and memory may be slower than younger counterparts, tasks should still be completed given adequate time. Vocabulary and verbal knowledge may actually improve with age.

It is not entirely clear why some people develop cognitive problems with age and others remain “sharp,” but it is likely a combination of genetics, environment and lifestyle. The Advanced Cognitive Training for Independent and Vital Elderly, or ACTION, study, funded by the National Institutes of Health demonstrated early cognitive training could provide a lasting benefit over time, specifically in the domains of thinking and learning.

As Mr. B left my office, I wondered what part of our conversation would resonate. Was it the diagnosis, the treatment plan? Or would he forget altogether our discussion about Parkinson”™s disease and the implications on his future? Once a physician makes a frightening diagnosis, a “brain barrier” often goes up to avoid the emotional turmoil that may potentially ensue. My job is to break down that barrier and ease any burden the patient and family carries, guiding them out of the gray zone. 

Dr. Jennifer Werely is associate medical director at the New England Institute for Neurology and Headache in Stamford, a practice dedicated to patient-centered care and clinical research. She can be reached at jen@neinh.com. For more information, visit NEINH.com.