Zoe: When my mom started to show signs of cognitive decline, that was stressful. And I think the most challenging part for me was everybody else. My dad, my partner at the time. They were just not seeing what I was seeing. They were making me feel like I was seeing things but I was really worried. Allison: That's Zoe. Like all of us, she's experienced day-to-day stress, but then a life-threatening incident sent her stress levels soaring. Not a good thing for anyone. Because now there's evidence that stress may increase dementia risk. You'll meet Zoe in a moment. Jay: Welcome to Defy Dementia, The podcast for anyone who has a brain. Allison: Defy Dementia is all about living in ways that keep your brain healthy and reduce your risk of dementia because dementia is not predestined by our genes. For sure, genetics can play a role, but lifestyle risk factors like poor sleep, loneliness, and poor diet may also increase dementia risk. Jay: Scientists are saying that if we make healthy changes to those lifestyle risk factors, we could reduce dementia cases worldwide by as much as 40%. Allison: Today on the show, stress and dementia risk. Science is showing that stress can take a toll on brain health and increase our risk of dementia, and we've got expert insights into how to reduce that risk. Jay: I'm Jay Ingram. I'm a science writer and broadcaster, and I've been writing and speaking about dementia for more than a quarter-century. Allison: And I'm Alison Sekuler, President and Chief Scientist at the Baycrest Academy for Research and Education and the Center for Aging and Brain Health Innovation. Join us as we Defy Dementia, because you're never too young or too old to take care of your brain. There is a growing body of evidence suggesting that stress and our reaction to it might elevate our risk for dementia. More research needs to be done, but today we've got some insights into stress that might surprise you. Jay: To set up that surprise, it might be helpful if we share a conventional definition of stress. This one is from the Mayo Clinic website. "Stress is a normal psychological and physical reaction to the demands of life. A small amount of stress can be good, motivating you to perform, but many daily challenges such as sitting in traffic, meeting deadlines, and paying bills can push you beyond your ability to cope." Allison: So what's so surprising about today's show? Well, you just heard that a little stress can be a good thing because it can motivate you. But our expert guest today, Dr. William Malarkey, does not use the term, "Good stress." He thinks that there's evidence that any amount of stress ages our brains over time, and that could lead to increased risk of dementia. Jay: And just to complete that definition of stress, the Mayo Clinic and other sources say that our brains are hardwired with an alarm system for our protection. When a brain perceives a threat, it signals the body to release a burst of hormones that increase your heart rate and raise your blood pressure. This flight or fight response fuels you to deal with the threat. These symptoms usually fade once the danger passes, but for some people, these stressed feelings continue. Again to quote the Mayo Clinic, "This prolonged or chronic stress can be very serious and have severe effects on a person emotionally, mentally, and physically. Don't wait until stress damages your health, relationships, or quality of life, start practicing stress management techniques today." Allison: That makes sense whether you agree that any stress is bad or not. In earlier episodes on Defy Dementia, we've tried to give out simple lifestyle advice on how to reduce dementia risk. Like on the nutrition show, we suggest you eat leafy green vegetables and colorful berries, or for exercise, park a little bit further away from the supermarket. Jay: Stress though is a harder nut to crack because not only do expert opinions differ on some points, but also because stress affects each of us differently and it can affect us deeply. But today on the show with the help from Dr. Bill Malarkey, we're going to set out strategies for becoming resilient to stress. We'll explore how it might even be possible to put the brakes on stress before it damages our brains and increases our risk of dementia. Allison: But first, a real-life story about surviving in a world of stress. Jay: Zoe is a 53 year-old social service worker with roots in the West Indies. What you need to know about Zoe is she's deeply into fitness. It has always been her go-to for stress relief. Zoe studied social work at university, began a family, and built a career helping youth, people who are homeless ,and those living with dementia. Fitness was her respite when, while raising several kids, her marriage ended. And in 2013 when her mom was diagnosed with early-onset Alzheimer's. That's when Zoe became what's often called a sandwich generation caregiver. A caregiver who looks after a parent at the same time as raising kids. Not an easy balancing act. There's one more thing you need to know about Zoe, that's not her real name. She asked us to call her that because she doesn't want her kids to find out that almost a decade ago she was nearly killed in a random attack. That brutal assault resulted in a criminal conviction for her assailant and a diagnosis of post-traumatic stress disorder for her. Zoe says she will tell her kids about the crime when it's time, but right now she's protecting them from growing up in fear of what happened. We should tell you before we start this discussion, it might be disturbing, but we hope that Zoe's story holds lessons for all of us on surviving and even thriving in the face of extreme stress. Zoe, welcome to Defy Dementia. Zoe: Thank you, Jay: Zoe, you've lived through a series of challenges. A full-time job, raising kids, the end of a marriage, and then your mom's diagnosis. Did the stress increase with each of those challenges? Zoe: It did, it definitely did. Having children and having your marriage end, it's hard for you, but you see that it's harder for your children. And so that really increases the stress. Because I know that I'm going to be okay, but my children didn't know what their world was going to look like and if they would be okay. When my mom started to show signs of cognitive decline, that was stressful, and I think the most challenging part for me was everybody else. My dad, my partner at the time. They were just not seeing what I was seeing and they were making me feel like I was seeing things. But I was really worried and that was really, really hard. So that was probably more stressful than her being diagnosed. Because it's so hard to worry about someone when everyone else around you is telling you there's nothing wrong. But in your soul you know something is wrong. Allison: And at each of those stages, was fitness always your go-to for stress release or did you have to change things up? Zoe: No, I think I was active in high school as a young person. I got my gym membership I don't know how many years ago, I should be on their board by now. So I always just like to work out. And when my children would be spending time with their dad and not with me over holidays, I'd be on the treadmill. A couple of tears would roll down, and I would just keep walking on the treadmill. Whenever I did not have my kids, I was at the gym. And I walked in not feeling good but I always walked out feeling better. Jay: Zoe, there's pretty good evidence now that stress contributes to dementia risk. Are you concerned about how all the stresses you've experienced might increase your dementia risk, especially since your mother has dementia? Zoe: My mom is living with dementia, we believe her father had late stage dementia. And we know not all folks receive a formal diagnosis, but sometimes it's pretty obvious. My dad lost a brother to dementia, a very rapidly progressive form of dementia. My dad's older sister has dementia, so I feel like I have dementia bullseyes pointed at me. So I want to live the healthiest life that I can for as long as I can. Allison: And in the introduction, Jay mentioned a really significant stressor that you experienced, and I'm wondering if you can share a little bit more about what happened to you about a decade ago? Zoe: You know, it was just a random act of violence. I was attacked by somebody wielding a pretty big knife. Someone kind of ran up to me and I thought they were running past me. I didn't realize what was happening until I felt something running down my face, it was my own blood. And the person tried to stab me in my face. They just cut me above my eyelid, and I held onto that knife for dear life literally. And both my hands got cut up, I almost lost a pinky, and I kind of just wrestled with this knife for as long as I could. And one thing, when I went to the emergency department and the doctor was checking me out before he sewed up my hand, he commented that, "Because I was in good shape, it's probably why I was able to hold off a person who was about a hundred pounds heavier than me." But I was saved by a good Samaritan. The only reason I'm here was because a good Samaritan came by and contacted the authorities and tried to get this person to stop. But they wouldn't even stop with the good Samaritan there. And at one point, the person lost their grip, because I was holding onto the blade, which was cutting through my hand. Allison: Oh my gosh. Zoe: And then I was able to pass the weapon off to the good Samaritan who then hid it from the attacker. But they continued to try to harm me by strangling me, and trying to take out my eyes, and suffocate me by sitting on me. But thank God for the good Samaritan, he saved me. Allison: And how did that feel in terms of your life, and you already had all of these stressors? Was this presumably not just one more stressor, but how did that affect your stress level? Zoe: I would say I kind of referred to my life like the time before and the time after. So everything changed, everything about me changed, and I feel like a different person now. And so I have to learn to love the person that I am now, because I can still be angry. I really liked the person I was before, if that makes sense. Jay: It sounds so bad. Calling it a stress is almost not enough. Zoe: Yeah, it's a nightmare. Jay: How are you able, even if your life does feel different now, how are you able to get through it? Zoe: Thank goodness I'm a mama. I'm a mama bear for my children. Honestly, for me that's probably been the saving grace. because I don't even think now I've gone for a full walk by myself out in public. And so even when I don't want to do something but they have their activities to do, my parenting propels me to continue living. And also because I don't want them to know what happened, because they were quite young when it happened. I just had to muster up the courage to just kind of go through the motions, keep living for them. Allison: Did you try to deal with it all on yourself or did you get help? Zoe: No, of course not. No, I knew from my scholarship and from my work that nightmares happen. But night terrors are not nightmares. They're very different. Once I had night terrors, I sought out my family doctor and I said I needed to see somebody. Allison: And did you have an official diagnosis then? Zoe: Yep, depression and PTSD. Allison: And what did you do? Before you were going to the gym to help you with your stress. Did going to the gym help here? Zoe: You know, I dreamt about going to the gym. I talked about going to the gym. I continued paying my gym membership in hopes that maybe one day I would show up to the gym. But I had to do a lot of hand therapy. I have some numbness and loss of sensation and mobility in some of my fingers, so I did extensive hand therapy for about 18 months. So that was all I could do, I did that and I did therapy with my psychiatrist. Allison: And what sort of therapy was helping? Zoe: So it's called, it's radical, it's called exposure therapy. Allison: Exposure therapy, what is that? Zoe: So for exposure therapy I had to narrate what happened to me over and over and over and over and over again. I guess the goal was to kind of desensitize myself to what happened. I was warned that it was tough and challenging. When they told me at my first session that having PTSD increases my chances of having dementia, that was a shocker to hear because I did not anticipate hearing that at my first therapy session. So I made a mental note that I was going to try really hard. Because obviously nobody wants to get dementia. I don't know. if it was like eight years ago and i have to talk about this situation, I'd be bawling by now. But I leaned into the therapy obviously because I'm a parent. I wanted to be able to function for my children, and I wanted to participate in the criminal justice system. And the thought of a two-week trial and being on the stand for possibly a week was kind of horrifying. That's why I worked really, really hard at the exposure therapy. Jay: Now Zoe, even though you say there's life after the attack and life before, and they're different, how are you doing now? Zoe: I wish I was doing better, if I'm being perfectly honest. I'm doing okay. It's funny, so PTSD shrank my world, just like dementia shrinks somebody's world. So I became very socially isolated, I guess people didn't know how to befriend me or console me so people stayed away. Just like what happens when someone is diagnosed with dementia. It makes people uncomfortable, and as a social work professional, I struggle with understanding that. I still don't do things by myself in public spaces. I've gone for a couple of walks, but I've had to be talking to somebody on the phone. So I'm getting better though, slowly but surely. Jay: Well, you've endured an incredible amount of stress. Is there one piece of advice on dealing with stress that you'd like to share with our audience? Zoe: I think going outside and getting some fresh air is a wonderful thing. It's even wonderful for folks with dementia. It reminds them that they're alive when they feel the cold air and they get a chill, and I know with my mom she kind of sparks up a little bit. So I think getting outdoors is really important. I think getting therapy is really important. I think culturally we don't talk about that enough, but I think it's important. If somebody needs a mood stabilizer, that's important. My mom's mood changed when she was diagnosed with dementia, and it was very sad to see her sad and paranoid. We put her on a mood stabilizer and she went back to her baseline. And for 13 years, people always comment that she's just the same woman that she was. She's a pleasant loving woman, and that's because she's on a mood stabilizer. And I think a lot of people with a diagnosis aren't happy, which is very sad. And when they're not happy, they're harder to care for by their loved ones, and that puts more stress on their loved one, which is also very sad. Allison: Zoe, thank you so much for sharing this really deeply personal story with us. And again, we're really happy that that bystander came by and that you are here joining us today. Jay: Yes, thanks. Zoe: Thank you. Allison: Zoe is a social services worker, a caregiver, and a mom. She joined us from Ontario. Jay: Our next guest has been listening to Zoe. Dr. William Malarkey has been a doctor since 1965. He studies the chemical messengers produced by our organs and glands to govern key body functions, but for the last two decades he's focused particularly on stress. Specifically on how stress impacts our brains, our behavior, our overall health, and, and this is key, how all those interact and influence each other. In his research, Dr. Malarkey has investigated why some people seem more resilient to stress than others. He's explored how factors like good physical health and strong personal relationships may enable us to reduce stress before it injures our brains. In his practice, he treats people living with stress and depression by helping them build their resilience. Allison: Dr. Malarkey is a Professor Emeritus at The Ohio State University College of Medicine, and Associate Director at the Institute for Behavioral Medicine Research, also at OSU. He works in Columbus, Ohio, but today he joined us from his vacation spot in the Florida Keys Dr. Malarkey Bill, thank you for taking a break from your vacation to help us defy dementia. Dr Malarkey: It's my pleasure, Allison, Allison: What struck you about Zoe's experience when you listened to her talking about it? Dr Malarkey: Well, what struck me was, number one, the severity of the stress, but more importantly, her ability to cope with it. From the knife to the post-traumatic stress she developed and discussed with us. And we could tell by the tone in her voice that she had overcome an awful lot of this, and it was now, at this point in time, not near as damaging, it would've been to most of us really. Allison: So when someone is stressed, whether it's through sort of ongoing day-to-day events or some kind of really traumatic event like the one that Zoe experienced, what's happening in the brain in those different cases? Dr Malarkey: The latest research on stress in the brain is that stress, when it is continuous and not balanced by an equal amount of resilience, will lead to inflammation. What the inflammation means is that our stress hormones have activated the immune system to secrete these compounds that go to the brain and interact with some important cells in the brain called glial cells. And they become inflamed. The cumulative effect of all these changes in the brain is the brain is aging, and if these products of inflammation have not cleared from the brain, it can lead to neuron degeneration and eventually dementia. Jay: What do you think are the key things that people need to understand about stress and its impact? Dr Malarkey: Well, I think probably the most important thing is that most moments in our life, like right now, is either a positive or a negative moment. There are some neutral moments in our life, but we kind of move around positive and negative. And quite often people tend to think about stress as a big event or a big issue. But really what really gets us over time are those small stressful thoughts or attitudes, of lack of forgiveness and anger. These are the things that really affect our immune system, our endocrine system, and lead to that aging process. We're all on an aging curve and stress can quickly make that a sharp turn south. Jay: I could be slightly stressed hoping that everything is going to go well with recording of this interview. Is that a stress worth paying attention to or is it too slight? Dr Malarkey: The issue about stress in our biology, and let's just take our endocrine system and our immune system, when we have a stressor, is that we tend to stimulate some of these processes. But in a healthy, resilient individual, they immediately come back to baseline. The problem comes when repeated thoughts and repeated daily stressful events are not well compensated for by our thinking and behaviors. That leads to a failure to come back to baseline. In all of our studies we see that people who are not handling stress well, whatever we measure, they come in with an elevated baseline as opposed to similar people without the same degree of lack of handling stress. Jay: Now Bill, you don't like to use the term good stress, and that concerns me a little because you've already told us that through the day we oscillate between not stressed, and stressed. Should I be worried about every single moment of stress I encounter during the day? Dr Malarkey: Well, if you're worried about it, you are making the problem 1, 2, 5, 10 times worse. It's part of living. We vacillate, we search out reward, we want to feel good. So we tend to direct our days where we have good feelings. which suggests that the pressures of the stressful part of the day are not working. So all of us have developed certain strategic thinking processes by way we can move aside negative thinking. For example, anger and lack of forgiving people for little events, all day long. People who are really doing well are able to make multiple forgiveness thoughts throughout the day. Now, if not, those endocrine immune influences are going to be more negative. Now, in 24 hours, no, it's not going to affect a lifetime. But we have a lot of 24 hours. When do we decide that we're going to work to try to change our thinking. The term we all use is "Stinky thinking" because that has physiologic consequences that over time we can see. And you've seen it in your friends, you've seen it in your business associates, we visually see this. That unmitigated negative thinking accelerates the aging process. The brain doesn't like accelerated aging. Jay: Bill, what is the best defense we can have against the negative effects of stress? Dr Malarkey: The best defense against stress - I've put together in a formulation based on my experience of studying people who lived to be over 90. And what I gathered from reading their obituaries were that people that were socially embedded, exercised, had good diet, and emotional intelligence, and some kind of spiritual aspect to their being did much better. So I think those features mark the person who's resilient and they have less symptoms. Jay: So you can build up your resilience to stress by paying attention to those factors? Dr Malarkey: That's correct. Jay: So am I able to use those qualities to judge my own resilience? Dr Malarkey: I would hope so. I don't see them failing in any way in my experience as I see patients in the clinic day to day, as I talk to my friends. But you know the experiment that we've all done, and that is. We go to high school reunions or college reunions, and you can already see the aging curves diverging quite significantly. So yes, all these factors are modifiable. If we don't have them, well, we're on a steeper aging curve and we're going to end up with dysfunctional brain function, yes. Allison: Yeah, it's interesting because I think also about my grandmother who was great in terms of her resilience until she was in her nineties. She had a great diet, she was very social, she interacted well with people, she walked six miles a day. Best legs any woman any age I ever met until she had a fall in her early nineties. And then she didn't get out as much to exercise and she became a little bit probably depressed and didn't socially engage, so everything that was high on your measures then started to go low and she later was diagnosed with dementia and then passed away at 96, unfortunately. But it was very interesting to see how she was keeping that stress in check I guess. This is the way I'm interpreting from what you're saying. Dr Malarkey: Yes. Allison: So is it the case that stress actually has a direct impact on dementia risk? Dr Malarkey: Oh, absolutely. No question about it. Huge. Jay: So if resilience is the key - and then you're very convincing when you tell us that - and I feel like maybe I'm falling a little short, where should I start to try and build up my resilience? Dr Malarkey: Well, this sounds like an office call. Allison: You're not going to charge us, are you? Dr Malarkey: Haha (laugh) yeah. Quite often I will see people, and you have friends like this, the doctors have evaluated them, they don't feel good, they got pain, they got aches, they got this, they got that. All their lab tests come back normal. The first thing I tell the patient when I sit down with them before we get into the resilience discussion, which they obviously have to have, is that everything in their body is probably off target. But we are unable as doctors and as laboratory people to prove it. Because there's a thing called the normal range problem, and no one knows what your sweet spot is in that normal range. You could be at 60% and have a normal lab test. So first of all, we have to assure people there is something wrong or you wouldn't have any symptoms. So now what do we do about it? There's a self-assessment tool, and sometimes we won't have time to discuss all that in the office, but I say, "Go home, put down these areas here and see where you need to change. And then keep a small diary, a day to day, and try to make some little changes. Not to be self-critical. Be mindful of how you approach it. Be kind to yourself, but try to make little daily steps in terms of building that resilience in your life." Jay: So there are other interventions that people discuss, like medications, mindfulness. Do any of those, including the two I just mentioned, and maybe others, are any of them effective? Dr Malarkey: Oh, definitely. For example, if someone was listening to our presentation here today and they're deeply into the depressed zone, they're not going to have the energy to do anything that we've talked about. Because they're so deeply depressed. And in fact, this talk would make them more depressed. Because they know what we're saying is correct, but they're unable to take step one. These people definitely need pharmacologic intervention. Probably at this point they're too deep to even benefit from cognitive intervention like behavioral therapies. But when they're able, then behavioral therapies can help them with improving. So yes, there is a time (for everything). And the self-reformation type stuff we're talking about, sometimes can't be employed until other measures are employed to get the person where they can make intelligent and forceful decisions to change their behaviors. Allison: So is what's going to work for one person, going to work for everybody? Or I'm thinking back to what Zoe told us. For her, exercise, going to the gym, that was her savior. That's what really put her over the edge in terms of her resilience and reducing her stress. So is it one size fits all or do different things work for different people? Dr Malarkey: Well, Allison, I think that one size does not fit all, and in fact, most people who are good exercisers, their spouse or their friends are not. So exercise is wonderful, but it certainly is not for all people. However, let's caution people not to take that remark, to be totally (sedentary) and just sit and not move. Because the body can rapidly decay in that situation. But I think that the first thing to do would be to find a friend. Friendship is critical to develop an attitude of gratitude. So if one can begin to feed those two areas, the sense of being grateful for whatever shape you're in and find a friend who can walk with you on this journey, (Its a good start). Its very difficult for people that are struggling from far behind to do this without friendship and I would really encourage them (to find a friend), because we all know how devastating loneliness is. it's now been declared a medical emergency in the state of California, New York, and a variety of other areas. So yeah, we need people. Allison: So helpful that advice. Do not try to go at it alone. Thank you so much for sharing your insights with us today, Dr Malarkey: Allison, it was my pleasure. Jay: Yes, thank you. Allison: Dr. William Malarkey is a Professor Emeritus at The Ohio State University College of Medicine. He joined us from the Florida Keys. Jay: You know Allison, really an interesting pair of interviews. Zoe is extraordinary, especially when it comes to resilience against the incredible stresses she experienced. And you can't help but think that some of the factors that Bill outlined, like fitness, strong social ties, especially her kids, emotional intelligence… All of those actually contributed to Zoe's resilience. The other thing that struck me is she talked about feeling socially isolated after her assault. And it shrank her world the way a world might shrink for a person living with dementia. And I think from what Bill said and from what we've heard actually throughout the podcast series, we need social ties to be healthy, people need people, and Zoe was able to fight through that isolation. Social connections, they're the key to brain health and dementia risk reduction. Allison: Yeah, absolutely, but I think it is key to remember that Bill talked about lots of different resilience factors, so social interactions, relationships for sure. But also physical health, your emotional health, engaging in intellectual activities, as we've called cognitive engagement. And even having a spiritual life where you might think of that also as having a purpose in life. And I think that one of the things that's really been emerging as a theme for us, as we've talked about these different factors across the whole Defy Dementia series, is that these multiple risk factors can gang up on your brain, but multiple lifestyle modifications can also work together to reduce your dementia risk. And that's what we've been calling this mixed bag. Jay: And people shouldn't be daunted by the idea of a mixed bag because there are many factors that influence your risk for dementia, but you don't have to address them all at once. You can start simply with one. And start simply on that one with just one change, so you don't have to do everything all at once. Allison: Yeah, and I think the thing that's really cool is that when you start with one, a lot of the time, others, sort of, come along for the ride. So if you say, "Okay, I'm going to start with exercise, I'm going to sign up for an exercise class." Yeah, you're going to get more exercise, but you're also getting social engagement, and you're also probably going to start eating better as a natural result of the exercise, and you'll start sleeping better. So some of these are sort of freebies that you get, they just come along. And the other thing that we should probably mention is that although Bill didn't get into it too much, there also can be a huge benefit for mindfulness and meditation when you're dealing with stress, and when we were doing our research for the show, for the episode, we spoke to a lot to different stress experts, and they all said that there's really good scientific evidence that mindfulness meditation actually does work, as long as you know what you're doing and you stick to it. Jay: I still think people should realize and accept that, we said at the beginning of this, stress is a tough nut to crack, and given that it's part of the mixed bag, you may get to the point where you feel you simply can't build the resilience that you need. And if you get to that point, if you're too stressed, if you're too depressed, it's really important to see a healthcare professional, because they can get you on that road to being better. Allison: To find out more about how you can reduce the risk of dementia or slow its progression, please visit us at DefyDementia.org. That's where you can find other episodes of Defy Dementia, as well as our animated videos, infographics, transcripts, and additional resources. Jay: Our podcast production team is Roseanne Aleong, Monique Cheng, Sylvain Dubroqua. Our chase producer is Ben Schaub. Production is by PodText, music is by Steve Dodd, and our cover art is by Amanda Forbis and Wendy Tilby. Allison: And we'd like to send out special thanks to Ngozi Iroanyah of Alzheimer Society of Ontario and Jhnelle McLaren-Beato of the Alzheimer Society of Canada, Jay: And a big thank you to the funder of this podcast series, the Public Health Agency of Canada. Please note that the views expressed here do not necessarily represent the views of the Public Health Agency of Canada. Allison: Your support is greatly appreciated, so please hit that subscribe button for Defy Dementia on Spotify, Apple Podcasts, Google Podcasts, or wherever you get your pods. I'm Alison Sekuler. Jay: And I'm Jay Ingram. Please listen to our next episode, it's all about caregiving as a risk for dementia. There's good evidence that looking after a loved one with dementia or other chronic diseases hugely increases the chances of developing dementia yourself. You'll hear some hard-won advice on how to look after yourself if you ever find yourself in the position of caring for someone. Thank you for listening to Defy Dementia, and don't ever forget, you're never too young or too old to take care of your brain.