S02_E16 - Dementia and Alzheimer's Disease

Speaker 1: 0:00

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Speaker 2: 0:04

Welcome to the Healthy Matters podcast with Dr. David Hilden , primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health, healthcare and what matters to you. And now here's our host, Dr. David Hilden .

Speaker 3: 0:20

Hey everybody, it's Dr. David Hilden , your host of the Healthy Matters podcast. And welcome to episode 16. We are gonna tackle the subject of Alzheimer's disease and dementia. Help me out. I've invited Dr. Anne-Marie , she's a colleague of mine here at Hennepin Healthcare in downtown Minneapolis, and a researcher into Alzheimer's disease , uh, and a geriatrician. And thanks for being back on the show with

Speaker 4: 0:43

Me. Great to be here. Thanks, Dave.

Speaker 3: 0:45

I have worked with you before on other broadcasting. We've talked over the radio waves. Now we're gonna do it in podcast form. So you have studied dementia your whole career. Could you lay the basics for our listeners? What is Alzheimer's disease? Or maybe what is dementia in general? Yeah.

Speaker 4: 1:02

Better to start with, what is dementia? So dementia is the umbrella term to describe a chronic progressive state of confusion. That includes memory loss and loss of ability to make decisions, to find the right words, to find things, and to navigate and eventually to be independent in your daily functions. Dementia is the general term, but there are many types of dementia. Alzheimer's is the most common, and it's important to distinguish Alzheimer's as a subtype of dementia versus all dementia. Many people think that Alzheimer's is all dementia, but it's the other way around. Dementia is the umbrella term, and Alzheimer's is a type. Other types are Lewy body dementia or frontal temporal dementia, early onset dementia. So that's kind of the overview, the definition.

Speaker 3: 1:59

How can you tell them apart?

Speaker 4: 1:59

Right. So really difficult to tell 'em apart initially. Usually, for example, for Alzheimer's disease, many of the characteristics seen in Alzheimer's disease are also seen in other types of dementia. But it's the timing and the association with other symptoms that makes the difference in the diagnosis. So for Alzheimer's disease, it's usually memory loss for recent events, recent memory loss versus remote or long distance memory.

Speaker 3: 2:31

So how is that different, or how do you know if it's a pathological or an abnormal process from the person who says, well, as I get older, I sometimes forget where I like put my checkbook. Right . How can you tell when is it a problem versus a normal process? Or is it ever a normal process? Um,

Speaker 4: 2:49

That's up for argument, whether it's a normal process, <laugh> , there are people in their one hundreds that are still without significant memory loss. So generally, if it starts interfering with your daily function to the point where it's making a big difference in your daily life. So it's not that you forgot where you put your keys. Maybe you forgot that you left your car in a parking lot, or you can't figure out how to get home from a neighborhood that's very familiar to you, or how to find your way home from say, an event downtown. When you've been doing that for 20 years,

Speaker 3: 3:26

Suddenly you don't know where you are, how you , how do I get home?

Speaker 4: 3:28

Right. Other things are forgetting something that happened yesterday, forgetting conversations completely and having family members start reminding you that we talked about this or that appointment was yesterday and we need to reschedule it. The frequency and the persistence of those episodes is what makes the difference. When

Speaker 3: 3:52

Does it begin in a person's life? Yeah.

Speaker 4: 3:55

So it depends on whether you're talking about when does it begin in the brain versus the symptoms in the brain. It begins about 15 to 20 years before the symptoms for most types of dementia for Alzheimer's, and more of the slowly progressive, what we call degenerative dementias. And we know that because there, there are brain autopsy studies that show that those brain changes. So amyloid and tau begin 15 to 20 years before the symptoms begin. Are

Speaker 3: 4:25

These the proteins in the brain that people have heard about? Right . Amyloid and tau, those are

Speaker 4: 4:29

The two most prominent proteins that we've been studying for many years. Now. There are other proteins that are involved in other types of dementia, but amyloid and tau are the biggest players. And

Speaker 3: 4:41

You said then about symptoms that those come on 10 to 15 years later after these changes begin in the brain. Mm-hmm. <affirmative> , what are the earliest symptoms? What are the first things and how would you know? How would a family member know?

Speaker 4: 4:53

Yeah . So short-term memory loss mm-hmm . <affirmative> is the earliest symptom word finding . Recurrent word, finding problems, persistent for reasonably common words. Mm-hmm. <affirmative> having difficulty planning your day using that, what we call executive function and decision making tools to plan your day. And especially kind of a , a litmus test if you want, is planning a trip. The ability to plan a trip with all the different components. You know, the flights , uh, the hotels is a very complex task that requires a lot of quote , executive function. Mm-hmm. <affirmative> , and sometimes people that have traveled worldwide, that's when it first shows up, is a very complex task like that because they're already extremely high functioning people.

Speaker 3: 5:37

Yeah. They've done this before. Yeah. They know how to do that. Yeah . And now they can't. Right. That's fascinating. So I'm gonna move on to like, in the population, how common is dementia and are they on the rise, the decline mm-hmm. <affirmative> in , in our country or

Speaker 4: 5:52

Globally. So a recent study that was published in the Lancet showed that it's actually on the decline in developed countries in mostly Western developed countries. So the

Speaker 3: 6:03

Lancet, one of the leading journals, medical journals ,

Speaker 4: 6:05

It's one of the leading medical journals in the world. Right. And it's believed that in part, that's due to decreasing cardiovascular disease and treating cardiovascular risk factors like high blood pressure and high glucose. So treating diabetes, but also higher levels of education across countries. So having a higher level of education is the strongest protective factor. We have to build up brain reserve to resist the changes of dementia.

Speaker 3: 6:36

And those are more prevalent in developed countries. So why do I hear then that dementia and related diseases are on the top list of causes of mortality death . Yep . Yep . We keep hearing that. And cardiovascular disease, heart disease is still number one, but getting better strokes are still way up there, but getting a little better. Right . But you hear about dementia on the lists of reasons for mortality. Why is that?

Speaker 4: 7:00

Right ? Right. Because the prevalence or how commonly it occurs increases almost doubles every 10 years after the age of 65. So you can't stop aging. Mm-hmm . Our population here and in many countries has accelerated aging. The aging population has grown to the point where right now, close to a third of the population in many parts of the US and the western countries are 65 and older, or it will be by 2050. Mm-hmm.

Speaker 3: 7:31

<affirmative> , is it similarly common in men versus women?

Speaker 4: 7:34

That's a good question. And still open for debate. Prior studies have suggested that it's more common in women, but those studies had some potential flaws. And more recent studies suggest that it depends on many other factors other than just being a woman. Don't

Speaker 3: 7:52

Women live longer? Is that one of them ?

Speaker 4: 7:54

Women live longer. That is a potential factor. Yeah. But that,

Speaker 3: 7:58

So there's more women of a, of a certain age. Yeah.

Speaker 4: 8:01

But that, that study and others have adjusted for that factor. Oh , they have. What

Speaker 3: 8:05

About, is it genetic? Is it hereditary?

Speaker 4: 8:07

So there's definitely hereditary component. Um, the a o e four genotype or type of genes that you have,

Speaker 3: 8:15

Do you know everybody's out there writing down a o e four? Yeah . And saying, should I get this? Yeah.

Speaker 4: 8:20

APO E and then the number four. So that's just a APO lipoprotein e And if you have one of the two genes for APO E four, you're at about three times the risk of having dementia, Alzheimer's disease, dementia. If you have both, you're at about 15 times the risk. However, there's still not enough clinical evidence in general to say you should run out and get that test because , you

Speaker 3: 8:49

Know, that's what I'm gonna ask you next. Yeah. Who should run off and get tested for these two

Speaker 4: 8:52

Kids ? 'cause there are so many other factors that play a role, especially education and lifestyle, nutrition, exercise, cardiovascular disease. If you already have heart disease, you're at higher risk of dementia. If you have high blood pressure, diabetes,

Speaker 3: 9:08

Those are the things you should be focusing. That's what you should not, whether or whether you have one of these two genes necessarily.

Speaker 4: 9:14

There are, however, a couple of companies starting to market a combination of tests with a o e four with one of the amyloid tests, but the results have to be in the right hands to provide the patient's guidance. Yeah. So it's not ready for prime time unless , for example, of patients being seen by a neurologist or a dementia expert.

Speaker 3: 9:34

So we're talking to Dr. Anne Murray about dementia, and we've, we've laid the groundwork on what is it and how common it is. So now I'm gonna ask you to shift a little bit , uh, who should be tested and how do you test for it? How do you diagnose it? So

Speaker 4: 9:47

Most often it's family members or friends that end up bringing a patient in for testing because the affected person is oftentimes the last to realize what's going on or to admit it. Mm-hmm. <affirmative> , it depends on what level of cognitive function they started with. If they were in a fairly demanding executive position, academic position, where they would've had , um, probably at least a college education and starting at a higher intellectual capacity, they're going to have symptoms earlier perhaps than those that don't start at such a high level. But most people aren't going to notice 'em .

Speaker 3: 10:27

They're able to hide it better. Are they intentionally hiding it? Or is it

Speaker 4: 10:31

They They often are, but not, not always that there's no universal statement regarding that really.

Speaker 3: 10:37

Right, right . Yeah . So higher education level, previous very high cognitive abilities might, might make it so that it's harder to find those symptoms.

Speaker 4: 10:45

Absolutely. And so if they have cognitive testing before they have more advanced symptoms, it may not show anything. So

Speaker 3: 10:51

How is it diagnosed?

Speaker 4: 10:53

It's diagnosed by cognitive tests and taking a good history. Otherwise, what is the story? When did the symptoms begin? Uh, when did your family or friends notice changes? And how is it affecting your daily function? How long ago did it begin? Usually by the time a person goes to a clinic to get it diagnosed, they've had symptoms for at least two years. And

Speaker 3: 11:16

Isn't that hard to pinpoint when it started? How long have you been Right . Getting this right . It's very hard . Few years. It's

Speaker 4: 11:20

Very hard.

Speaker 3: 11:21

It's getting worse over time. Some days are better than others. It's probably hard. Yeah. Do they do actual formal written cognitive testing?

Speaker 4: 11:29

They do. It varies by what specialists you go to see. If you're starting with your primary care clinic, there are some cognitive tests that can be given. And depending on the results and the extent that the provider has worked with dementia patients, they can design a plan in terms of, well, are you ready for medications? Or is it time to get some blood tests ? And, and maybe we should refer you for further evaluation. If you're going to a geriatrician or a neurologist, they can usually do more of that workup right away. Whereas primary care physicians, as all physicians, have limited time to see each patient. No ,

Speaker 3: 12:10

We have nine minutes. You know? Yeah.

Speaker 4: 12:11

I mean, it's absurd. There's no way you can do cognitive testing unless you have an extended visit and bill Medicare for that, which never covers the costs .

Speaker 3: 12:20

Never really does. What about clinics that are specifically designed to treat older adults?

Speaker 4: 12:24

Sure. So at Hennepin Healthcare, we have two senior care clinics, one in Brooklyn Park where we have several geriatricians and our geriatric fellow. And then at the Clinical Specialty Center here on the Hennepin campus, Dr. Emily Ssq also does memory assessments.

Speaker 3: 12:43

Our geriatrics division is simply top-notch. We're gonna take a quick break now, and when we come back, I want to talk a little bit more about some preventive things you might be able to do. Also gonna talk about current treatments and importantly, what is down the road for future treatments in research into dementia. We're talking with Dr. Anne Murray from the division of Geriatrics and a dementia researcher here at Hennepin Healthcare in downtown Minneapolis. Stay tuned. We'll be right back after a quick break.

Speaker 2: 13:09

You are listening to the Healthy Matters podcast with Dr. David Hilden . Got a question or comment for the doc, email us at Healthy matters@hcme.org or give us a call at six one two eight seven three talk. That's 6 1 2 8 7 3 8 2 5 5. And now let's get back to more healthy conversation.

Speaker 3: 13:32

And we're back talking about dementia with Dr. Anne Murray from Hennepin Healthcare. And you mentioned a little bit in our first segment that there are some things that people can do to lower their risk. I don't know if you would call those preventive, but you can lower your risk. Absolutely. And you talked about heart disease, diabetes, exercise. Can you say more about that please?

Speaker 4: 13:49

Absolutely. There have been several studies that shown that you can reduce your risk of dementia by about 40% or more just by maintaining a healthy lifestyle. Foremost is exercise. Just taking a 20 minute walk a day is enough to reduce your risk of dementia. Doing more is better, but 20 minutes a day of exercise that gets your heart rate up. And other things like weightlifting yoga. What about

Speaker 3: 14:17

Doing crossword puzzles or exercising your brain? Is that Yeah. So

Speaker 4: 14:21

Physical, physical exercise is actually more important. It's

Speaker 3: 14:23

More important

Speaker 4: 14:24

Comparatively. That's

Speaker 3: 14:26

Fascinating. Is that because of increased blood flow to the

Speaker 4: 14:28

Brain? Yes. It's because of increased blood flow from the heart to the brain. And there are hormones in the brain that are triggered by exercise that increase blood flow and decrease some nerve damage.

Speaker 3: 14:41

One more reason to get out and walk.

Speaker 4: 14:44

Right.

Speaker 3: 14:44

Right . What about what I've just said though, is that a myth or does is exercising your brain help? I meanly your brain doing wordle every day or something like that?

Speaker 4: 14:51

Yes. Exercise in your brain does help. The key is to keep your brain as active as it has been in whatever ways you have been doing and add new challenges. Even picking up an instrument or maybe trying to learn a new language, picking up some kind of new skill is a benefit. But do not watch tv.

Speaker 3: 15:13

<laugh> for crying out loud. There's a new show I found on Netflix. It's gonna make my brain literally atrophy.

Speaker 4: 15:19

I should not say that.

Speaker 3: 15:20

No, that's probably right. You're not active. Okay. There , lots of us like to sit down and binge Netflix sometimes. Is that actually harmful?

Speaker 4: 15:28

Only if it's prolonged sitting time and not using your brain. Well,

Speaker 3: 15:33

It totally is prolonged sitting time. Well, for many people, for

Speaker 4: 15:36

For many people two hours to watch a Netflix movie is okay. But you have to counterbalance it with exercise. Yeah. Right.

Speaker 3: 15:44

And I of course am on a treadmill when I'm watching TV continuously.

Speaker 4: 15:47

Right, right. <laugh> as aren't we all, aren't

Speaker 3: 15:50

We all okay. What <laugh> . Okay. So TV is maybe not quite so good. Physical exercise is good. What about the disease processes? You mentioned earlier treating heart disease and diabetes and the like. Why would those be helpful?

Speaker 4: 16:02

Because the same risk factors that increase your risk of heart disease and stroke, increase your risk of dementia. So the things that increase heart disease are high blood pressure, high blood sugar, diabetes, high blood lipids,

Speaker 3: 16:18

Cholesterol,

Speaker 4: 16:19

Cholesterol, a poor diet and unhealthy diet. And maintaining a normal body weight is really important. More important even than the body weight is your waist circumference. And when I say waist , it's not your belt measurement, it's the biggest part of your abdomen is the waist circumference.

Speaker 3: 16:39

So I will , I will , uh, uh, alert listeners. We did a show on weight management with Dr. Aisha Galloway Gilliam , and just a few weeks ago here in season two. Go back in here that we talked about that the apple shape of a body. Right? Not in your hips, that big gut that you have

Speaker 4: 16:53

Having abdominal fat. So for example, having a pot belly doubles your risk of dementia because there's enough fat breakdown, fat metabolism, the energy that goes into trying to break down the fat increases inflammation and that inflammation is bad for your brain. Wow.

Speaker 3: 17:12

Let's shift to treatments. Now you've studied treatments and for some years mm-hmm. <affirmative> are the ones, first of all, that have been around for a while . Effective. There are some medications, for instance,

Speaker 4: 17:22

Right? Yeah. There are two primary medications. Um, Aricept or Donepezil and Memantine or naa , they work on different nerve chemicals. So the Aricept works on the acetylcholine neurologic system. And in doing that, it prolongs how long acetylcholine stays around to transmit nerve signals. The EDA slows down a different system. It's called the glutamine or the glutaminergic system, and it decreases the production of glutamine, which is bad for the brain. So

Speaker 3: 17:57

Are these medicines clinically significant? Yeah. Can people tell that they worked?

Speaker 4: 18:01

Some can. Yeah. Um, overall, probably 60 to 70% of people will see a benefit if they have dementia due to Alzheimer's disease, potentially less effective in Lewy body disease. Um , may be effective in parental temporal dementia, but in some, there's no effect in others. There seems to be a little bit of a jump of an improvement right away. And then they stabilize and decline slower or more slowly than they would've if they hadn't been on the medication for about up to about two years. And

Speaker 3: 18:35

These have been around a long time. They've been around 10, 20 years probably, right?

Speaker 4: 18:38

Yeah , about 20 years. What

Speaker 3: 18:39

About aspirin? Is that doing anything?

Speaker 4: 18:41

So funny. You should ask <laugh> .

Speaker 3: 18:43

Dr . Murray knows more than any living human being I know about aspirin. I I'm planting that question.

Speaker 4: 18:49

Yeah . So there was a large, an ongoing study called the aspirin and reducing events in the elderly study

Speaker 3: 18:56

Ri

Speaker 4: 18:57

RI conducted in Australia in the us and we here at the Berman Center, at the Hennepin Health Research Institute are still the coordinating center. And we found that after about five years of taking low dose , a hundred milligrams of daily aspirin to see if it would reduce the risk of dementia or disability or death, it did not do any of those things. It also did not reduce the risk of cardiovascular disease. So for ,

Speaker 3: 19:21

It was based on that trial that you were leading in this country and with your worldwide partners, a daily aspirin of roughly a baby aspirin dose . Yeah . That was roughly a baby aspir .

Speaker 4: 19:30

Yeah .

Speaker 3: 19:30

Um , uh, didn't do anything to, to reduce the risk of getting dementia. Didn't make people live longer, didn't help their heart. That was a groundbreaking study. Were you disappointed? We,

Speaker 4: 19:40

Everybody was disappointed. Not completely surprised, because the bottom line was that the bleeding risk far outweighed any potential benefits . So 40% increased risk of severe bleeding on aspirin compared to those who are on, not on aspirin. So

Speaker 3: 19:54

That's aspirin. We've talked about the two, the two biggies that are out there. What about what people are reading about in the newspapers all the time, hearing on the news, there's a new drug for Alzheimer's disease, or there's a new drug for dementia in general. What's the latest , uh,

Speaker 4: 20:07

On that ? So the , the latest that is being given out in selected centers under clinical observation is Lecan Map , which is an anti amyloid medication that is believed to decrease plaques. So pre-existing plaques,

Speaker 3: 20:23

Amyloid plaques in the brain, it actually reduces their presence

Speaker 4: 20:27

A little bit. It may, in some patients also improve their memory or decrease their dementia symptoms because

Speaker 3: 20:34

Isn't that what you're after? That's what you're after. Does someone really care if I have fewer plaques in my brain, if it didn't result in any improvement in my life?

Speaker 4: 20:41

They don't, especially if the plaques have been there for so long, they're probably not making a difference anymore. Right. They're more, more of a scar than anything.

Speaker 3: 20:48

Are you encouraged by these? Are you , uh, do , is there a promise in these new Well,

Speaker 4: 20:51

There are

Speaker 3: 20:52

Biologic treatments is what they are

Speaker 4: 20:54

Somewhat. I think that we have to be aware that there are many different ways to get dementia, many different types of nerve damage to produce dementia, Alzheimer's. So amyloid and tau are not by any means, the only ways to get it. And so we have to devise ways to address all those other different types of cells, to devise medications, to treat those. And that's why no treatment has been a panacea. Nothing has really worked well.

Speaker 3: 21:20

Right. What about non-medication resources , uh, that are out there? Yes. I know people in my own life that use the Alzheimer's organization

Speaker 4: 21:28

Services . The Alzheimer's Association is wonderful. And we in Minnesota, North Dakota, have a wonderful chapter. They have , uh, tremendous amount of information for caregivers as well as for those experiencing memory loss. That includes resources for finding in-home health caregivers, support groups, daycare centers, what's available for daycare centers, for those who are already along the path with moderate dementia. A lot of good ideas on what steps to take next, because

Speaker 3: 21:58

It's really about the caregivers as well. Oh , this is not a disease that people do on their own. Right . They , it's a , it's a, there's , it takes caregivers and loved ones and support systems and professionals.

Speaker 4: 22:09

Yes. And the caregivers know that better than anybody. It tra makes , takes a tremendous toll on the caregiver. And oftentimes it's hard to remind them because they're so dedicated that you have got to take care of yourself, because if you don't, who's gonna take care of your family member? So there've been actually a lot more research studies in the past 10 years supported by National Institute of Aging to look at caregiver research and how to support them. So I

Speaker 3: 22:34

Happen to know that you do have done a lot of this research over your career and you continue to be actively doing internationally based research and right out, right out of here in downtown Minneapolis. What are you working on right now? Sure.

Speaker 4: 22:46

So there's a new study that just began enrolling called The Healthy Aging through the senior years, or the hats study. You

Speaker 3: 22:55

Guys always come up with acronyms.

Speaker 4: 22:57

<laugh> have to be able to remember them. Um, and this is a , a very exciting study that we're doing here at the Berman Center at Hennepin Health, together with the Mayo Clinic. This is a collaboration with Mayo where we are adapting the study design that Mayo created for their , um, Mayo Clinic study of aging, to study dementia and other diseases over the long term , but now enrolling black participants. Mm-hmm . And we've been very fortunate to work with two community engagement partners, Clarence Jones with his Humane Group and Monisha Washington with her link group that have been great in helping us engage with community and begin enrollment.

Speaker 3: 23:38

Much research over the years has not included people of color. That's right. And so this one specifically does,

Speaker 4: 23:44

This is specifically targeted to that. And we're , um, hoping to enroll about 300 participants over the next two and a half years. We have some funding through Mayo philanthropic funding. We are applying for more both through N I H and through the Minnesota Research Partnership with the University of Minnesota through the state. So , so

Speaker 3: 24:03

I'm hearing a lot , uh, although it's a big burden for our community, it affects so many of us, our families. Um , dementia does, I'm hearing some positive things. I'm hearing some new treatments down the road. I am hearing about the Alzheimer's Association as an incredible resource for people. And I'm hearing about the research that you're doing that sounds like there are some promising things down the road.

Speaker 4: 24:23

Absolutely. I think there will be in the next 10 years or so, successful treatments, not to cure, but to slow it. And in the future to prevent it. We will

Speaker 3: 24:34

Put a link to the hats trial on the show notes. So, great. Fantastic, fantastic.

Speaker 4: 24:38

Listeners,

Speaker 3: 24:38

Fantastic . Um , go there. Please look at it and see if , uh, that might be something you or a loved one or someone you know, might be interested in and be part of the solution to dementia. I have been talking with my colleague, Dr. Anne Murray, who is a researcher, a geriatrician, and a colleague of mine here at Hennepin Healthcare in downtown Minneapolis. Thank you so much. Not only for being here today, but for helping me out to learn about these topics over the last couple of decades since we've been working together and for all the work you're doing for our, our communities.

Speaker 4: 25:09

My pleasure. It's been fun.

Speaker 3: 25:10

It's great to have you here. We've been talking about dementia with Dr. Ann Murray . I hope you have picked something up. I have learned a ton in this episode. And if you liked what you heard, give us a review , uh, wherever you get your podcasts and share these podcasts with your friends and neighbors. That's all we have for today. And thank you for tuning in listeners, and I hope you'll join us for our next episode. In the meantime, be healthy and be well.

Speaker 2: 25:33

Thanks for listening to the Healthy Matters podcast with Dr . David Hilden . To find out more about the Healthy Matters podcast or browse the archive, visit healthy matters.org. You got a question or a comment for the show? Email us at Healthy matters@hcmed.org or call 6 1 2 8 7 3 talk. There's also a link in the show notes. And finally, if you enjoy the show, please leave us a review and share the show with others. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas At Highball Executive Producers are Jonathan, CTO and Christine Hill . Please remember, we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well.