(Sadly, we missed the first 12 minutes; future Class Colloquium
00:12:41.000 –> 00:13:02.000
We use last, while the lyrics daughter paper has received somewhat less attention than I would think of it as, as it merits. In any event, so that brings us to sort of the big picture of of Alzheimer’s disease, the prevalence is extraordinary.
00:13:02.000 –> 00:13:15.000
In several series. A third to a half of over 85 population are believed to have major cognitive either cognitive pathology or symptomatic cognitive decline.
00:13:15.000 –> 00:13:34.000
the clinical correlation has been known for years to be imperfect, it is possible to have house our pathology and those symptoms. It’s possible to have full blown Alzheimer’s pathology, have the time of death, and be a marine cognitively intact.
00:13:34.000 –> 00:13:52.000
On the day of on the day of your demise. So the, the, the best correlate of Alzheimer’s of clinical Alzheimer’s status on the particular day, is whether your, your synaptic density is intact or impair.
00:13:52.000 –> 00:14:12.000
Yet the structural pathology, the accumulation of amyloid plaques and tangles has drawn the for the lion’s share of the attention. But in, indeed, almost no one would disagree that the more important feature is the integrity of synaptic density.
00:14:12.000 –> 00:14:18.000
So I think with with that overview, let me see if there are questions, or anyone wants to add something.
00:14:18.000 –> 00:14:30.000
Before we jump into the, into the main text art does that give you a sort of the 30,000, foot view you were you were seeking
00:14:30.000 –> 00:14:35.000
your Amir you’re on mute aren’t.
00:14:35.000 –> 00:14:49.000
Thank you, it does indeed. Would you be kind enough to comment upon why so many Alzheimer’s drugs have failed. And what’s the prospect for drugs going forward.
00:14:49.000 –> 00:14:58.000
So I think we were slow to realize how early all summer methodology begins.
00:14:58.000 –> 00:15:17.000
There probably there’s probably the in the study that we did in patients who had temporal epileptic temporal lobes amputated looking at AP for one of the major risk factors, we found that Alzheimer pathology is detectable in people with risk genes, as
00:15:17.000 –> 00:15:24.000
early as the 40s. That is the four year, the fifth decade of life.
00:15:24.000 –> 00:15:45.000
Your quality is defined clinically as an over 65 clinical onset, in fact pathology is present from the 40s and 50s. So we we’ve been slow to do. Well, it’s been a challenge to identify these folks pre clinically, and to to predict which of them, which
00:15:45.000 –> 00:15:57.000
folks with ALS are pathology will develop clinical Alzheimer’s disease. And we’ve now sort of segregated health our pathology from clinical Alzheimer dementia.
00:15:57.000 –> 00:16:21.000
We now see our methodology can occur, you know, if is, as I mentioned later six different, unique recognizable molecular history logical entities, even the World Trade Center responders who have developed an astounding prevalence of PTSD and dementia
00:16:21.000 –> 00:16:41.000
seem to be accumulating Alzheimer disease as a virtue as a, as a result of being exposed to the cleanup on the pile at the ground zero, so it’s it’s it’s a lot of diseases and the pathology begins way before we we thought we recognized and the pathology
00:16:41.000 –> 00:16:57.000
does not guarantee the clinical, it does not perfectly mirror the clinical situation, what we’re what we’re missing is a way to monitor synaptic density in the brain of living subjects from really from from birth to death.
00:16:57.000 –> 00:17:12.000
Would we presume accurately that synaptic density means that the neurons at in that area are still alive as opposed to, they’ve suffered demise. Is that what density measures, sir.
00:17:12.000 –> 00:17:28.000
So we need to two pieces we need to know that they’re there. And we need to know that they’re functioning. So, until we have those readily available. It’s hard to to to take an accurate snapshot.
00:17:28.000 –> 00:17:42.000
We need both the anatomy of the synapses and Scott will be, there’s a new pet like and from Yale that you may have heard about that may, they may represent intact synapses.
00:17:42.000 –> 00:17:56.000
But we also need things like functional MRI to and pep, tell us whether those synapses that are intact are still happy and and functioning properly so we need both structure and function of synapses together, a good picture.
00:17:56.000 –> 00:18:03.000
Clearly, density of plaques and tangles ain’t getting us where we need to be okay.
00:18:03.000 –> 00:18:15.000
You’ve mentioned a very glad you’ve mentioned a very important point and that is that there are signs of Alzheimer’s change.
00:18:15.000 –> 00:18:18.000
10 or 20 years before clinical diseases evidence.
00:18:18.000 –> 00:18:27.000
Are we able, are we able to visualize that radio graphically or through other methods, could you discuss that place.
00:18:27.000 –> 00:18:49.000
We have been able to them we are currently able to see amyloid plaques, we can see similar amyloid, so there’s a little subtlety here that amyloid is a normally produced protein, the forms from the, the metabolism of a larger parent protein called the
00:18:49.000 –> 00:19:00.000
amyloid precursor clever name, but the, the, a important feature of this amyloid fragment that’s that’s generated.
00:19:00.000 –> 00:19:20.000
Is it exists in a variety of what are called conferences that are best compared to prion like structures that is their present in various folding states that have been that remain challenging to detect it during life, but it’s clear that each of these
00:19:20.000 –> 00:19:38.000
folding states, there could be 10 there could be hundreds, or we don’t know how many folding states there are, but they have a variety of biological activities, it’s very clear that the most the most typical folding structure of the amyloid fibro is actually
00:19:38.000 –> 00:19:41.000
one of the least poisonous forms of animal right.
00:19:41.000 –> 00:19:57.000
And in fact it’s the more disordered sort of clump of the Polymer. That’s way more neurotoxic and the fibro In fact, the fibro the highly structured form main back the protective, while the, the,
00:19:57.000 –> 00:20:06.000
The bus here. The the glob globular form that says more disordered maybe the more toxic.
00:20:06.000 –> 00:20:22.000
All right, if we could ask you asked me about about about visualization so it’s possible to see amyloid five roles during life, it’s not possible to see amyloid polymers during life so it’s not again it’s not possible to see either the, what we think
00:20:22.000 –> 00:20:33.000
is the most toxic form of amyloid or to determine whether that toxicity is is being exerted in the person’s brain at the at the at the moment of that scan.
00:20:33.000 –> 00:20:45.000
So it’s possible to see amyloid plaques. It’s not possible as the amyloid polymers, it’s possible to see tangle structures, it’s not possible to see Tao polymers.
00:20:45.000 –> 00:21:04.000
Again, all of these are, these proteins exist in a variety of structures that have different biological activities some benign some toxic and almost, very little of that is appreciable in the living human brain.
00:21:04.000 –> 00:21:08.000
Okay.
00:21:08.000 –> 00:21:13.000
Is there a point in time.
00:21:13.000 –> 00:21:26.000
Speak if you would show how the diagnosis is made, and I’ll call Dr. Morrison him as well if he would like to speak to this, how do we make the diagnosis of Alzheimer’s disease.
00:21:26.000 –> 00:21:49.000
So, so the diagnosis of Alzheimer’s disease is now a clinical radiological or Glencoe biomarker event that is patients who are recognized by themselves or by their family members and carers, to have to begin failing and their cognition, changing in the
00:21:49.000 –> 00:22:03.000
changes in their personality, maybe inability to form, and retrieve new short term memories. The most famous and often parodied symptom of Alzheimer’s disease is the inability to form and retrieve new short term memories.
00:22:03.000 –> 00:22:22.000
Family members often notice, perhaps in great frustration makes aspiration, a family member who says the same makes the same observation were asked the same question every few minutes, as though and you with no recognition that he or she has asked that
00:22:22.000 –> 00:22:35.000
question just five minutes. Hence, and it, it’s, it drives, family members, crazy. I can tell you that from personal experience as a, as a family member.
00:22:35.000 –> 00:22:53.000
And that’s how the that’s the most common sort of presentation, however, often, the, the inside of the patient is impaired early on, and the patient will never for the entire rest of that person’s life, recognize that there is a there’s a problem.
00:22:53.000 –> 00:23:12.000
Those folks are some of the most challenging to diagnose this so they are often seen by a, a primary care physician and neurologist a psychiatrist. The first order of business is to exclude reversible causes of cognitive impairment, usually that includes
00:23:12.000 –> 00:23:17.000
a panel of blood tests and brain imaging usually an MRI.
00:23:17.000 –> 00:23:28.000
There are rare forms of metabolic which is thyroid disease, or slow growing structural does
00:23:28.000 –> 00:23:41.000
lesions like blood, blood clots are tumors that can mimic Alzheimer disease, those are rare but they have specific interventions. Once the MRI is is negative in the blood test reveals nothing.
00:23:41.000 –> 00:23:59.000
We may go on to perform quantitative neuro psychological assessment to get a picture as to whether this person’s cognitive decline matches the pattern that we expect for either Alzheimer disease, or something says, such as vascular and cognitive impairment
00:23:59.000 –> 00:24:06.000
and dementia. So another very common often concurrent illness with with Alzheimer’s disease.
00:24:06.000 –> 00:24:27.000
Beyond that, there are two others sorts of studies were formed for documentation. One is the Florida the oxy glucose PET scan and these are the standard PET scan helps distinguish all cyber disease which characteristically shows by parietal or asymmetrical
00:24:27.000 –> 00:24:35.000
by parietal hypo metabolism versus other forms of dimensions as it Frontotemporal dementia.
00:24:35.000 –> 00:24:40.000
Beyond that one last piece of data that we require at this point.
00:24:40.000 –> 00:24:47.000
for exclusion or including the diagnosis of Alzheimer’s disease is to detect whether amyloid.
00:24:47.000 –> 00:25:04.000
The amyloid level is abnormal in that person’s brain either by spinal fluid analysis to see whether amyloid is being depleted from the spinal fluid as it as it deposits in the brain, or through an amyloid PET scan were a specific type of login is used
00:25:04.000 –> 00:25:10.000
to visualize amyloid five rolls, not all the numbers in the brand.
00:25:10.000 –> 00:25:12.000
Okay.
00:25:12.000 –> 00:25:31.000
So if I could clarify one point. I’m family of someone who is showing signs that leaves the family to be suspicious would seek out the patient’s doctor and present the symptoms for memory loss of short term memory.
00:25:31.000 –> 00:25:46.000
If I heard you correctly, and the evaluation including blood is, there’s no blood test for Alzheimer’s disease, but the blood tests done would be inclusive or exclusive of other pathologies is that correct.
00:25:46.000 –> 00:25:50.000
So this is a rapidly moving area.
00:25:50.000 –> 00:26:05.000
There is now a marketed in many states, not in, not in New York, and not in Pennsylvania I think are the two excluded states at the moment, There is a blood test for amyloid.
00:26:05.000 –> 00:26:09.000
The, the different sizes of amyloid that are are present.
00:26:09.000 –> 00:26:30.000
However, while that’s available in many states. Just last week, a that whole story was revisited by some major biomarker experts from Europe, who have reported that this marketed test is in sufficiently robust to us to be applicable for for broad screening.
00:26:30.000 –> 00:26:42.000
This is again a major evolving area where the new test is announced hailed widely studied, and then sort of backtracked.
00:26:42.000 –> 00:26:53.000
So I, I have to tell you that there’s a lot of interest in this area and will certainly be your patients would be more accepting of blood tests and off have asked for blood tests.
00:26:53.000 –> 00:27:03.000
But that’s what we sort of our transition so now as you know maybe we have something maybe we’re not maybe we don’t maybe it’s not as good as we had hoped it.
00:27:03.000 –> 00:27:05.000
Thank you.
00:27:05.000 –> 00:27:10.000
Dr Danny if I could, I’m going to turn some attention to dr Morrison.
00:27:10.000 –> 00:27:15.000
Dr Morrison.
00:27:15.000 –> 00:27:36.000
Thanks, thanks are and I guess a little curious about where you want me to go here, because we can certainly continue to talk down talk along the path of Alzheimers disease and I know, Sam wanted to talk a little bit about the new medication edge Academy,
00:27:36.000 –> 00:27:52.000
or what I had planned to do was step back a little bit up to about 30,000, feet, and take a look at the challenges of an agent society. In the United States, in particular, related to as you had asked, both palliative care and Alzheimer’s disease and
00:27:52.000 –> 00:27:56.000
just curious as to where you want to go. And I’m open to going either way.
00:27:56.000 –> 00:28:13.000
I think we would be happy to have the 30,000 foot perspective.
00:28:13.000 –> 00:28:27.000
When we come to have suspicion about the integrity and health of our loved ones. What steps, would you would we be taking at that time to initiate evaluation.
00:28:27.000 –> 00:28:37.000
Dr. Gary has just touched on some of that I’d like to give people a bit of a formula that they can take home that they can feel confident that they know the first steps to take.
00:28:37.000 –> 00:28:51.000
When they have reason to be suspicious. Yeah, it’s a really good question. So let me start with that and there’s a couple of questions in the chat that I’m going to tack on and then on leave for Sam for others on the question is has all timers recently
00:28:51.000 –> 00:29:11.000
increased or as the publicity of those diagnosis increased I think the answer to that is probably both on that. When we look at when we go back in 2019 on us, longevity reached the highest that has ever been in all of human existence that the average
00:29:11.000 –> 00:29:15.000
age of death for somebody’s born in the United States was about 78 years old.
00:29:15.000 –> 00:29:22.000
And if you think about the fact that less than 150 years ago, the average age of death was 45.
00:29:22.000 –> 00:29:26.000
On that is a remarkable increasing longevity.
00:29:26.000 –> 00:29:39.000
And along with that, not only are people living longer, but there are a lot worth living longer as the baby boomers age, and in 2030 for example for the first time in all of human history.
00:29:39.000 –> 00:29:45.000
The number of adults over the age of 65 will eclipse the number of children under the age of 18.
00:29:45.000 –> 00:30:01.000
We have never seen that before, in all of human existence and Alzheimers disease is a disease of older adults on the more people that are aging, the greater numbers, the more we’re going to be seen.
00:30:01.000 –> 00:30:15.000
Alzheimers disease related dementias. And indeed, multiple forms of chronic counts. Because hundred years ago when you were diagnosed with heart failure, you had a very short life expectancy.
00:30:15.000 –> 00:30:18.000
Now your life expectancy is very very long.
00:30:18.000 –> 00:30:32.000
And, and I think this is work, this is a, this is something. This is work as a result of scientists have Dr Danny, Dr. Davis, is that Alzheimers disease is a disease.
00:30:32.000 –> 00:30:36.000
It’s a disease like hypertension. It’s a disease like cancer.
00:30:36.000 –> 00:30:45.000
It’s a disease like heart failure. And yet, because it’s a disease of the brain, there is a stigma associated with it.
00:30:45.000 –> 00:30:48.000
There is a shame associated with it.
00:30:48.000 –> 00:30:56.000
And like cancer was in the 1950s it’s something that people still are reluctant to talk about.
00:30:56.000 –> 00:31:02.000
And yet it is nobody’s fault that they develop dementia.
00:31:02.000 –> 00:31:05.000
They didn’t do anything wrong to develop it.
00:31:05.000 –> 00:31:13.000
And, as Dr Gandy has said it’s a disease that affects not only the person, but their family and their loved ones as well.
00:31:13.000 –> 00:31:24.000
And I think the more that we’re seeing people articulating that they have a disease of the brain, as opposed to the disease of the heart, the more this will.
00:31:24.000 –> 00:31:27.000
The more people will be able to seek treatment.
00:31:27.000 –> 00:31:30.000
The more people will be able to access medical care.
00:31:30.000 –> 00:31:46.000
And the more families will be able to be supported. So to come back to your question what do families do. The first is, is to be aware of it, and to raise it both with their family member, and with their physician.
00:31:46.000 –> 00:31:53.000
If somebody if some. If my wife or my father was having chest pain.
00:31:53.000 –> 00:31:55.000
I’d want their doctor to know about it.
00:31:55.000 –> 00:31:59.000
I’d want them to say, am I do I have.
00:31:59.000 –> 00:32:03.000
If I’m beginning to forget things.
00:32:03.000 –> 00:32:07.000
If I’m noticing short term memory gaps.
00:32:07.000 –> 00:32:09.000
I’d like to know if I have a disease.
00:32:09.000 –> 00:32:18.000
And so yes it is really important to bring those questions to your physician, you’re treating physician.
00:32:18.000 –> 00:32:27.000
And as Sam said, there are a number of, there’s a what we call a differential diagnosis for cognitive impairment or memory loss.
00:32:27.000 –> 00:32:36.000
There are things that are easily treatable. For example, depression, the things which are much more difficult to treat all stars Alzheimers disease is an example.
00:32:36.000 –> 00:32:45.000
Um, there’s some things, simply adjusting medications, so it’s important to bring these concerns because not every memory problem is all times disease.
00:32:45.000 –> 00:32:52.000
And that is really important to get the right diagnosis. You know I’d like to band senility.
00:32:52.000 –> 00:33:05.000
Having a senior moment just losing my mind, just like a band that, because that’s the just that there’s something inherently wrong with the person that’s not.
00:33:05.000 –> 00:33:27.000
And so then getting the right diagnosis and moving to the right treatment, and treatment for Alzheimers disease, like any other serious chronic illness is family based care, its treatment for the person, whether that’s
00:33:27.000 –> 00:33:35.000
drug therapies, behavioral therapies support groups, its treatment for the families.
00:33:35.000 –> 00:33:44.000
It is really hard being a caregiver of somebody with Alzheimer’s disease. Sam talked about the frustration of living with somebody who sometimes you forget that they have short term memory loss.
00:33:44.000 –> 00:33:53.000
They’re not asking the same question over and over again because they want. They want to bother you. They’re asking because they really can’t remember it.
00:33:53.000 –> 00:34:01.000
So it is that support for caregivers which is critically important, and its financial.
00:34:01.000 –> 00:34:08.000
Amy Kelly one of our faculty here, did a study.
00:34:08.000 –> 00:34:21.000
I guess about three years ago, that looked at the impact of Alzheimers disease on patients, families, and across the United States on families lost a third of their wealth, paying for the care for somebody with Alzheimer’s disease that was not covered
00:34:21.000 –> 00:34:30.000
Families lost a third of their wealth, paying for the care for somebody with Alzheimer’s disease that was not covered by insurance.
00:34:30.000 –> 00:34:34.000
That’s a lot higher if you’re a woman at 60%.
00:34:34.000 –> 00:34:39.000
It’s a lot higher if you have less than a high school education. That’s almost 50%.
00:34:39.000 –> 00:34:42.000
And for persons of color is exceedingly high.
00:34:42.000 –> 00:34:50.000
So 85% so it’s about also thinking about appropriate financial planning to care for yourself and your families.
00:34:50.000 –> 00:34:54.000
Does that answer the question, aren’t quite well thank you.
00:34:54.000 –> 00:35:17.000
As you give a 30,000 view perspective. Can you comment, perhaps, inclusive in that about whether our healthcare system actually has adequate financial resources to handle these issues, whether there are more bit of these that you see in your work that
00:35:17.000 –> 00:35:33.000
could be prevented if people approach them differently. Prior to late life. Maybe you can even speak to, assisted living nursing cares. Some of the things that would be remedies for people and families encountering these illnesses.
00:35:33.000 –> 00:35:39.000
Absolutely.
00:35:39.000 –> 00:35:48.000
Because Ken, I’ve known can for the entire time I’ve been at Sinai, which is a little shorter than his but not by much was about 25 years.
00:35:48.000 –> 00:36:09.000
And the reason, one of the major reasons that I stay. And that I love this institution has been the focus on population health, and the focus of creating a health care system to meet the needs of the future, rather than today and can, you know, can as
00:36:09.000 –> 00:36:25.000
Sam said is you know world renowned all timers, scientists, and yet what he’s done as CEO of the health system is create a model of care for the future and that’s why I stay here, because that’s what keeps me up at night is exactly what you pointed out
00:36:25.000 –> 00:36:33.000
artists how much we’re spending on health care, and where we’re going on. so let me just put this into context again.
00:36:33.000 –> 00:36:46.000
We are living in an extraordinary time on the fact that the average age of death pre covert was almost 80 years old, is something we have never seen in all of human existence.
00:36:46.000 –> 00:36:59.000
The fact that, again, prior to Cove it 100 years ago, leading causes of death in this country the top five leading causes of death were infectious diseases.
00:36:59.000 –> 00:37:03.000
and that 40% of deaths occurred and children
00:37:03.000 –> 00:37:11.000
is something we don’t think about or at least until two years ago we didn’t think about anymore. For most of us can reach the age of 65.
00:37:11.000 –> 00:37:23.000
On the next 20, or so years, because that’s what life expectancy is for people who reach 65 is going to be one of good health.
00:37:23.000 –> 00:37:28.000
Many are gets going to be work and ongoing work.
00:37:28.000 –> 00:37:33.000
It’s going to be strengthen your relationship with loved ones. It’s about life completion.
00:37:33.000 –> 00:37:35.000
And yet.
00:37:35.000 –> 00:37:47.000
Overwhelmingly, all of us are likely going to develop one or more serious illnesses, which we’re going to live with for many many years before we die, including Alzheimers disease.
00:37:47.000 –> 00:37:52.000
And when you look at our healthcare system right now.
00:37:52.000 –> 00:37:56.000
It’s a really poor match for that population.
00:37:56.000 –> 00:38:03.000
When you look at for example symptom burden of living was serious illness.
00:38:03.000 –> 00:38:18.000
The average person with furred failure stroke cancer dimension with COPD, or one disease. You know 40 to 50% of those people have four or five bring some symptoms would say with with on a daily basis, which we need to address.
00:38:18.000 –> 00:38:35.000
When we look at disability, both physical and cognitive disability. For those of us in our, you know, mid 50s, which is, I guess I’m late 50s now. You know, one and five need help with a household activity.
00:38:35.000 –> 00:38:42.000
But for those aged 80 and over, that number gets above 60%.
00:38:42.000 –> 00:38:53.000
And so, 60% of those over the age of 18 you can even somebody help with their banking, finance management. Getting groceries.
00:38:53.000 –> 00:39:01.000
40% are going to need help with just getting around in terms of walking.
00:39:01.000 –> 00:39:05.000
And so we’re going to need caregivers.
00:39:05.000 –> 00:39:24.000
We’re going to need somebody to help us get through the day. And that’s where we also have a big challenge, because, as the number of older adults increases the number of younger adults who are traditional caregiving workforce decreases.
00:39:24.000 –> 00:39:33.000
And in 2030, where our health care expenditures are predicted to hit you know 20 to over 20% of our GDP.
00:39:33.000 –> 00:39:45.000
The number of people over the age of 65 is going to be greater than the number of women aged 18 to 55, who’s our traditional workforce. So we have to figure out.
00:39:45.000 –> 00:39:47.000
Within the next 10 years.
00:39:47.000 –> 00:39:53.000
How to change our healthcare system for a better match to the population at need.
00:39:53.000 –> 00:40:05.000
And, you know, we spend more than one and a half times on health care than our leading neighbor.
00:40:05.000 –> 00:40:12.000
And yet when we look at life expectancy in the United States, it’s sort of in the on the order of Cuba.
00:40:12.000 –> 00:40:24.000
So, what do we need to do. And this is where I think Mount Sinai has been one of the key leaders. The first is we need to focus on population health.
00:40:24.000 –> 00:40:32.000
And we need to focus on health, rather than medical care. And that means thinking about families as units of care.
00:40:32.000 –> 00:40:38.000
It means being able to deliver care where people live not bringing care to the institutions.
00:40:38.000 –> 00:40:44.000
So that means, for example, hospital I services for people at home.
00:40:44.000 –> 00:40:53.000
It means innovative models of caregiver support that don’t rely on you having to pay a home health attendant.
00:40:53.000 –> 00:41:04.000
It means fundamentally restructuring.
00:41:04.000 –> 00:41:09.000
If I have a chain, I can’t get across Park Avenue the amount of time with the light goes.
00:41:09.000 –> 00:41:13.000
It’s not designed for our population.
00:41:13.000 –> 00:41:26.000
And we need to start thinking about treating serious chronic illness, as well as we treat acute medical events, And that requires us to redesign our healthcare systems.
00:41:26.000 –> 00:41:30.000
What are the models that work yes assisted living as a terrific model.
00:41:30.000 –> 00:41:38.000
You know the aging in place models, but there’s not enough.
00:41:38.000 –> 00:41:51.000
We have really no good models for people with advanced serious illness or advanced dementia, besides the nursing. And I think none of us think our American nursing homes or a good model for delivering chair on.
00:41:51.000 –> 00:41:56.000
So we’ve got to be creative and innovative around us.
00:41:56.000 –> 00:42:06.000
And I, you know, I live in hope that Sam and his colleagues are going to have that treatment for Alzheimer’s disease given my family history.
00:42:06.000 –> 00:42:17.000
And at the same time, there’s a lot of us out there who will never benefits, we’ve got to think about what is our healthcare delivery system going to be doing rather than simply our basic science.
00:42:17.000 –> 00:42:23.000
And that’s where I think we need the innovation and that’s where I think we need the new models of care.
00:42:23.000 –> 00:42:30.000
The Japanese experience with gerontology doesn’t have anything to teach us yet because they’re terrified.
00:42:30.000 –> 00:42:41.000
I get asked to come speak in Japan because they’re trying to figure out what to do, because their population is aging faster than ours.
00:42:41.000 –> 00:42:49.000
And I noticed somebody said they have great Long Term Care Insurance kept by Long Term Care Insurance anymore, folks.
00:42:49.000 –> 00:42:55.000
Those who bought in earlier lucky but he can’t do it anymore.
00:42:55.000 –> 00:42:57.000
So we got to fix it.
00:42:57.000 –> 00:43:02.000
We got to fix it.
00:43:02.000 –> 00:43:03.000
Oh, bring.
00:43:03.000 –> 00:43:04.000
Hurry.
00:43:04.000 –> 00:43:09.000
Pressing but
00:43:09.000 –> 00:43:22.000
I do. Um, I’ve been looking over all the questions and sort of summarizing them or combine them together and let’s stay on this topic of the 30,000 foot level.
00:43:22.000 –> 00:43:34.000
Although I find the scientific medical explanations useful I can’t really understand it as well as I can understand the day to day forgetfulness.
00:43:34.000 –> 00:43:40.000
Just to the to know my sister has all timers, and I.
00:43:40.000 –> 00:43:47.000
Every morning I wake up wondering whether it’s be next because I indeed had been turned down for long term care.
00:43:47.000 –> 00:43:51.000
And I actually did manage to get it.
00:43:51.000 –> 00:43:54.000
But they insurance company.
00:43:54.000 –> 00:44:07.000
When, when they called me they just basically essentially said, out of hand that it was unlikely that they would ensure me, based upon my sister’s diagnosis.
00:44:07.000 –> 00:44:19.000
So, let me just ask a cup. So I come at this with a sort of an appointment set of pre thoughts.
00:44:19.000 –> 00:44:25.000
But let me ask a couple of common things that I think a lot of people are asking.
00:44:25.000 –> 00:44:40.000
First of all, are there any verifiable dietary side effects from some drugs variation of some other diseases such as diabetes associated with Alzheimer’s or other dimension.
00:44:40.000 –> 00:44:50.000
Because you see it you know an immense amount of stuff on the TV advertising about this, and, you know, rather than just rejected out of hand.
00:44:50.000 –> 00:44:58.000
Is there any evidence that anything can help this condition. Sam you want to tackle them.
00:44:58.000 –> 00:44:59.000
Yeah, sure.
00:44:59.000 –> 00:45:24.000
So there’s compelling evidence that medication diet and lifestyle factors associated with good cardiac health is also reflected in good brain health. So that’s one typical guideline I usually discuss with my patients and their and their family.
00:45:24.000 –> 00:45:45.000
That is, cholesterol level body weight control of diabetes, all these things that when, when uncontrolled increase risk for poor, poor cardiac health are all also risks for poor brain health.
00:45:45.000 –> 00:46:01.000
The over the counter medicines that you see advertised every five minutes on TV, have are almost certainly snake oil with little or no, no.
00:46:01.000 –> 00:46:08.000
verifiable facts. So I don’t think there’s anything there that’s.
00:46:08.000 –> 00:46:29.000
Among the things that are touted that are that are real. However, there are real benefits in sustaining good cardiac health, those factors. In addition, with, well, I guess, in particular, the mind, diet, mind, described by Mia kV Balto building on the
00:46:29.000 –> 00:46:45.000
work of Martha clear Maurice has does appear to show specific ways to modify diet, in particular, in such a way as to improve both cardiac and brain health.
00:46:45.000 –> 00:47:13.000
Now, over and above diet and dietary issues lifestyle including mental stimulation mental engagement, and social engagement, are all things that help keep the brain healthy in ways that we can’t always identify, but in ways that seem absolutely verifiable
00:47:13.000 –> 00:47:43.000
by multiple investigators that is engaging and reading or or active, use of your synapses to stimulate their, their, their strengthening and and proliferation seems to be a good thing there clearly are roles for inflammation, and there are both dietary
00:47:49.000 –> 00:48:07.000
So, so, social engagement as well, that is being engaged with other humans. There is something about engagement with other humans, that seems to stimulate the brain in ways in beneficial ways, over and above what you get from stimulating the brain with
00:48:07.000 –> 00:48:30.000
with with you my reading or becoming engaged in in thinking, exercises. So all these things, cardiac health inflammatory modulation and functional stimulation of our brain activity and socialization, are all good things.
00:48:30.000 –> 00:48:34.000
Okay, another question that has occurred on.
00:48:34.000 –> 00:48:40.000
How do you distinguish between normal forgetfulness, and something pathological.
00:48:40.000 –> 00:48:50.000
And I’ve certainly had that discussion with my doctor and I don’t think I’ve gotten a good answer. Other than he says oh you’re okay.
00:48:50.000 –> 00:48:55.000
Which is a little bit disconcerting when you have someone else in your family who has all time.
00:48:55.000 –> 00:48:57.000
Yeah.
00:48:57.000 –> 00:49:17.000
Sean you want me to take this. Go ahead, Sam. Yeah. Yeah. So, um, it’s it’s very individualized but I think it’s, you know, the, the important combination is a sort of a thoughtful listener as a physician and the attempt to help Chen help judge on an
00:49:17.000 –> 00:49:32.000
individual basis, whether that person’s cognitive and executive function seems to have peaked and is now, for whatever reason, on the wane whether it’s a depression and dementia a metabolic brain disease.
00:49:32.000 –> 00:49:53.000
So, unfortunately, physicians aren’t always as comfortable with this conversation as they might be, and might not take the opportunity of being asked to sort of jump in with both feet and have the have the long serious conversation about how a particular
00:49:53.000 –> 00:50:03.000
into individual and their family can judge whether their, their brain is failing
00:50:03.000 –> 00:50:15.000
No i know i i don’t think there’s much to add except again the fact that sometimes people are worried about bringing it up. Yeah, I mean we do if you when I’m not sure.
00:50:15.000 –> 00:50:34.000
That’s one place I definitely want to use neuropsychological testing, because that then gives me, functional assessment matched by your normed by age and educational attainment, to try and determine whether this person is likely or not to be undergoing
00:50:34.000 –> 00:50:53.000
brain failure in a way that’s, that’s a pattern that we recognize as pathological other areas now there’s not a, there’s not a Yeah, and other words there is no website you can go to and take 100 question tests and indicate any kind of indicators to what
00:50:53.000 –> 00:51:04.000
what might be going on for armed when you talk to somebody about this, there are plenty of claims to that, but none of which I would refer my patient.
00:51:04.000 –> 00:51:13.000
I think the other thing, Harry that I have to add to that is that as physicians we don’t get good training in how to do.
00:51:13.000 –> 00:51:30.000
Cognitive assessments, the way we do in terms of physical diagnosis. And so when you go to met many times when you go to a physician and say, you know, is this abnormal or is this normal age related changes.
00:51:30.000 –> 00:51:43.000
They don’t know the difference. And so that’s why it really is important to seek out somebody who does work in this area via a neurologist a psychiatrist or a geriatrician because we don’t do.
00:51:43.000 –> 00:51:49.000
We don’t do enough education in
00:51:49.000 –> 00:51:53.000
distinguishing
00:51:53.000 –> 00:51:56.000
pathological from non pathological changes in memory.
00:51:56.000 –> 00:52:01.000
And these are not all together comfortable conversations.
00:52:01.000 –> 00:52:18.000
And I almost always try and blurt out the a word to sort of break the ice, early on is that I’m sure you’re asking about this because you’re concerned about whether you’re, you might be at risk for Alzheimer’s disease.
00:52:18.000 –> 00:52:36.000
That’s not always welcome. I don’t always use it, bring up, say the word in the first time I see someone and back and almost never do. But I always wonder when I’m going to say it the first time in a particular situation, because it’s usually the unspoken
00:52:36.000 –> 00:52:42.000
event but it’s you know it’s a bell, it’s impossible to unwrap.
00:52:42.000 –> 00:52:49.000
Another question. I’m a little different is, how is the Japanese experience with gerontology.
00:52:49.000 –> 00:53:02.000
Does it have to have anything to teach us the answer that that they’re they’re just as exasperated agitated fretful as we are.
00:53:02.000 –> 00:53:11.000
And looking for how to, how to manage the you know the unknown the oncoming so called silver tsunami.
00:53:11.000 –> 00:53:19.000
Okay. Um, let’s see.
00:53:19.000 –> 00:53:39.000
There’s a question about brain training, take advantage of the brain plasticity to slow down the progression of either dementia or Alzheimer’s. is there any value in in the non pharmaceutical of things that are being offered to people these days in terms
00:53:39.000 –> 00:54:00.000
of stimulation of the brain by various activities, or I think we, I think that was that Sean indicated that there was some, you know, obvious benefit to that but what is the value, and we were all looking for ways that we can do something, as opposed
00:54:00.000 –> 00:54:07.000
to feel completely at this this Could I come on us, and there’s nothing we can do about it.
00:54:07.000 –> 00:54:15.000
I mean it’s one thing that I neglected to mention before which is important and was oversight on my part, I’d like to correct that is the importance of physical exercise.
00:54:15.000 –> 00:54:35.000
And, you know, among these, you know the the cardiac diet things have become quantified, and with within just the past few years, it’s become clear that at least 30 minutes, at least, 30 minutes sessions at least three times a week of vigorous exercise
00:54:35.000 –> 00:54:49.000
brisk walking or weight training does act as a drug is usable as a prescription to manage the risk for cognitive decline. So physical exercise stimulates perhaps as evidence.
00:54:49.000 –> 00:55:03.000
A Mio kind called IRI sun IRI si n is released from the muscles during exercise and has a good effect or salutary effect on the brain so physical exercise.
00:55:03.000 –> 00:55:12.000
In addition to diet. And these the mental stimulation and socialization that I mentioned before, is an essential part of the whole picture.
00:55:12.000 –> 00:55:31.000
In terms of whether there is a whether we can reduce cognitive stimulation to a similar prescription. There’s lots of effort to do that. Some early signs of that might be possible, but I would not say that there’s a definitive prescription for Lumosity
00:55:31.000 –> 00:55:50.000
or whatever, then I would say is definitely usually using these, these if when a patient or caregiver whoever utilizes these brain training exercises what they get is better at that brain training exercise.
00:55:50.000 –> 00:56:05.000
It doesn’t tend to generalize to their usual to their their their daily existence, so they become their test score gets better so they feel like they’re doing something and maybe they are, but we haven’t yet shown that the, the, sort of the coin of the
00:56:05.000 –> 00:56:21.000
realm here is activities of daily living. And we want to see something that has impact on ADL on the scores of how people’s how people get through their lives and and maintain themselves as as independent entities.
00:56:21.000 –> 00:56:23.000
Yeah, ask your question.
00:56:23.000 –> 00:56:26.000
Dr Danny.
00:56:26.000 –> 00:56:32.000
Getting back to diagnosis, if we’re looking for early clues.
00:56:32.000 –> 00:56:44.000
Is there any looming optimism for a blood test or something that is a simple qualifier of risk or a diagnostic threshold.
00:56:44.000 –> 00:56:52.000
Well there’s certainly hope for these blood tests, and we we may have some combination of blood tests that will be useful.
00:56:52.000 –> 00:57:04.000
Sort of less specific for dementia, but, more, more clearly, robust is simply a measure of brain health, such as neuro filament light chain.
00:57:04.000 –> 00:57:20.000
That seems to be a sort of a like I like I said rate for your pre your brain, in terms of seeing whether there’s something about your sort of some general evidence that your brain and it fits your neurons are not happy, and levels of in the blood of neuro
00:57:20.000 –> 00:57:40.000
filament or NFL can change with multiple sclerosis, stroke, a variety of things, so we may have sort of a combination of specific markers maybe for Alzheimer pathology, together with markers of synapse synaptic integrity and measures of neuronal health
00:57:40.000 –> 00:57:52.000
like NFL, so that we may be on the customer, having these things be more generalizable and usable, we’re not quite there yet, but I’m optimistic that we’ll we’ll get there.
00:57:52.000 –> 00:58:06.000
But more important, will be things like pi genetic risk scores that are usable on the individual level, because we’re going to want to intervene in people that who we think are loaded for risk for late life degeneration.
00:58:06.000 –> 00:58:25.000
But, in whom that has not yet begun to intervene early to predict reliably who’s at the highest risk, an individual level, who’s going to who’s who has the risk for dementia, and we’ll go on to develop that and be able to intervene early on with something
00:58:25.000 –> 00:58:28.000
safe, affordable and effective.
00:58:28.000 –> 00:58:41.000
That’s that will that will can be used to sustain neural function synaptic function and, and ward off or prevent this degeneration.
00:58:41.000 –> 00:58:59.000
A question for each of you let me ask Dr galley. Is there a threshold difference for women, compared to men since the women are more twice as likely it seems to encounter a diagnosis of Alzheimer’s, with the thread with the, with the evaluation the treatment
00:58:59.000 –> 00:59:00.000
the workup.
00:59:00.000 –> 00:59:09.000
The concern, come in a different time a different phase of life is the threat is the particular to look different.
00:59:09.000 –> 00:59:22.000
So, in the same way that I mentioned where I’m sort of revealing that Alzheimer’s disease maybe six different there at least six different illnesses. It seems to be different in men versus women.
00:59:22.000 –> 00:59:41.000
So I don’t have a specific answer yet at the clinical level that we’ve operationalize, how we evaluate women versus men, but we certainly believe that, especially with with inflammation and other factors that contribute to generation during all of our
00:59:41.000 –> 00:59:54.000
disease that there is some sex specific or what we call sexual Morpheus that the parts of the disease or either qualitatively or quantitatively different in the different sexes.
00:59:54.000 –> 00:59:57.000
Thank you,
00:59:57.000 –> 00:59:59.000
Dr Morrison. Yeah.
00:59:59.000 –> 01:00:15.000
Um, could you comment as to what a, a prudent yearly or every two year frequency of testing would be in the geriatric population, for, for people without specific illness.
01:00:15.000 –> 01:00:26.000
What would you recommend that the audience take away is the frequency of evaluation by a gerontologist, and what kind of testing would you recommend.
01:00:26.000 –> 01:00:35.000
So, in the absence of, you know, a serious chronic medical illness.
01:00:35.000 –> 01:00:43.000
The vast majority of people over the age of 6570 or 80 need a good primary care physician and don’t need a geriatrician.
01:00:43.000 –> 01:00:50.000
So what do I, what do I screen for on a regular basis on.
01:00:50.000 –> 01:01:08.000
It’s really straightforward. I do, I screen for cognition, you know, a straight forward in office screening test for memory, and other forms of and other areas of cognition.
01:01:08.000 –> 01:01:24.000
I screen for function. I make people get up from a chair walk down the hall turn around and come back. Um, so can I can see that they don’t have a gate disorder, and that they’re not at risk for a fall on the other things that you would normally look
01:01:24.000 –> 01:01:27.000
for blood pressure monitor
01:01:27.000 –> 01:01:50.000
good physical exam, but most of us don’t need routine medical testing, and the absence of symptoms, and many of you may have seen Jane Brody’s column in the New York Times today about perioperative testing and that oftentimes we do testing just to test
01:01:50.000 –> 01:02:07.000
up. The other thing that. and then the very straightforward things a screening for cholesterol for people who need it. Routine health maintenance mammography vaccines vaccines vaccines vaccines vaccines.
01:02:07.000 –> 01:02:18.000
But that’s what I would look for and then obviously that changes for somebody who’s living with a chronic illness or multiple chronic illnesses,
01:02:18.000 –> 01:02:24.000
What do we speak to the vaccines that you’d like to recommend for older population.
01:02:24.000 –> 01:02:25.000
I’m sorry.
01:02:25.000 –> 01:02:32.000
Would you speak to the vaccines, or an older population. Make sure your tennis is up today.
01:02:32.000 –> 01:02:34.000
flu shots yearly.
01:02:34.000 –> 01:02:49.000
And, high, high dose flu shots for those who qualify pneumonia vaccine covert vaccine coded vaccine coded vaccine coded vaccine.
01:02:49.000 –> 01:02:50.000
Peace.
01:02:50.000 –> 01:02:57.000
I’m sorry I’m shingles shingles shingles. Thank you.
01:02:57.000 –> 01:03:00.000
And the new shingles vaccine. Absolutely.
01:03:00.000 –> 01:03:02.000
Okay.
01:03:02.000 –> 01:03:13.000
We’ve been at this about an hour with your gracious participation, we can drag on a little longer or we can have a few more questions from, from Harry.
01:03:13.000 –> 01:03:16.000
I don’t want to.
01:03:16.000 –> 01:03:34.000
I don’t want to have ill effects your afternoons, and we thank you very sincerely Harry Do you have anything that you’d like to ask is a digital cluster so I’d like to close out with a personal question which is what is the
01:03:34.000 –> 01:03:39.000
role of heredity, and in this disease.
01:03:39.000 –> 01:03:56.000
If you have a sibling or a father or mother, who has been diagnosed what is the what is the likelihood that you will certainly, obviously elevated but my father didn’t have it but my sister did.
01:03:56.000 –> 01:04:09.000
I’ll let Sam answer that, but I’ll answer the question that everybody asks me as a geriatrician as you know what’s the success for living long and well is to pick your parents.
01:04:09.000 –> 01:04:15.000
Straightforward is that, but I’ll I’ll let Sam answer the other way.
01:04:15.000 –> 01:04:27.000
Yeah, so the straightforward answer I think is that for for first degree relatives of someone with Alzheimer’s disease the risk is considered to be about double.
01:04:27.000 –> 01:04:49.000
The most common genetic risk factor for Alzheimer’s disease known and perhaps there will ever be known, is the AP for Elio, of which you inherit one from each parent, you have one e4 ll that triples the risk for Alzheimer’s, you have to have a belief
01:04:49.000 –> 01:05:02.000
four levels. The risk goes up by about 12, fold. It’s, it’s imperative a multiplicative enhancement. That’s even greater than, then simple arithmetic.
01:05:02.000 –> 01:05:11.000
So almost, almost no one with two AP four levels, escapes Alzheimer’s. yet some do.
01:05:11.000 –> 01:05:25.000
So we, and much of what we’re learning now is about how this happens, that is how it is folks with Alzheimer pathology sustain normal function in the face of it.
01:05:25.000 –> 01:05:41.000
And this is something we call resilience, And that is how those synapses keep firing happily how those neurons keep functioning normally. Despite the accumulation of protein deposits.
01:05:41.000 –> 01:05:53.000
Between and inside brain cells, and the inflammation that this protein opt in genders.
01:05:53.000 –> 01:06:04.000
Thank you. What one response to dr Marrs and is indeed choose your parents well my parents both died when they were 91.
01:06:04.000 –> 01:06:17.000
My sister was diagnosed when she was 72. So I’m actually encouraged to hear that I should focus on my parents, and keep a good sense of humor, I suppose.
01:06:17.000 –> 01:06:33.000
Thank you. Um, if I can speak to both of our speakers today, I want to sincerely thank you for the gift of your time and your expertise, so thank you for telling us in this unique setting, we are ever grateful and our understanding and information augmented
01:06:33.000 –> 01:06:43.000
by your gracious participation to the group at large. We’re going to break out by residential college now.
01:06:43.000 –> 01:07:13.000
If you’d like to test your memory and your ability to choose the right words. Please select from one of the 12 residential college breakout groups offered by Wayne on your screen momentarily.