🎙 Dementia vs. Alzheimer's Ep. 10

This month's MedEvidence guest, Dr. Steven Toenjes, MD, a board-certified neurologist, former staff neurologist in the U.S. Navy and an award-winning director of neurology residents at the Uniformed Services University of Health Sciences and decorated Navy veteran, joins Dr. Michael Koren, MD and Michelle McCormick to discuss Alzheimer's disease in a four-part series. 

With over six million Americans believed to have Alzheimer's disease and the sixth leading cause of death in the United States, MedEvidence breaks down Dementia vs. Alzheimer's, including diagnosis and treatments.

If you enjoyed this episode, you will loves these:

• Is it Alzheimer's or Something Else?
• Alzheimer's Disease: The Hullabaloos of Aduhelm!
• The Future of Alzheimer's Research

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Original Air Date: March 11, 2022

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Have a question for Dr. Koren? Email him at askDrKoren@MedEvidence.com

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Music: Storyblocks - Corporate Inspired

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Transcript

Michelle
Welcome to MedEvidence Truth Behind the Data. Today we are talking with Dr. Michael Koren and Dr. Steven Toenjes about Alzheimer's disease. Let's first introduce Dr. Koren. Dr. Michael Koren is a practicing cardiologist and CEO and founder of Encore Research Group. He has been principal investigator of multiple trials and has been published in the most prestigious journals. Also joining us today, Dr. Steven Toenjes.

Michelle
He's a board certified neurologist and principal investigator on multiple trials at Encore Research Group. He is a decorated Navy veteran and has been practicing neurology in Jacksonville for over ten years. Gentlemen, welcome today. Thanks for having us. Yeah, I'm excited. This is a good topic, if I remember correctly. I think we have a good topic ahead of.

Dr. Koren
Us, if you remember correctly.

Michelle
Yes, if I remember correctly. All right. So we're going to be talking today about Alzheimer's disease, the breakdown. Dementia versus Alzheimer's. Now, some people think that it's the same thing. What's the difference? Let's go there.

Dr. Koren
Well, we'll let the neurologist jump in. This is definition, and then I'll give you the cardiovascular definition.

Dr.Toenjes
So that and that's a very, very common question. I must hear multiple times a day in the clinic. First, dementia is a term that really refers to the severity of a cognitive deficit. It doesn't really refer to an etiology for that cognitive deficit. So if the cognitive deficit is sufficient enough and in degree that it really starts to impact what we would refer to as activities of daily living.

Dr.Toenjes
Basically, your your ability to care for yourself, essentially that that we would call a dementia. But dementia doesn't really have any reference to the cause. You can have a dementia if you've had Alzheimer's disease for a number of years. If you drink a fifth of vodka every day, eventually you'll you'll have a dementia from that behavior. So the term dementia purely and simply is a reference to the severity of a cognitive deficit.

Dr. Koren
Is there a technical skill that you look at as a neurologist that tells you somebody is either impaired mentally or actually demented?

Dr.Toenjes
There's there's a number of them. But quite frankly, we we really just split up activities of daily living, you know, things like paying bills, driving probably one of your more common technical technically activity of daily living that gets people labeled as having difficulty specifically with activities of daily living is medication administration. If you cognitively can't, you know, manager on medication, that's technically a failure of an activity of daily living.

Dr.Toenjes
So there's not any specific skill, but there are dementia rating skills, there's many mental skills, there's all kinds of skills. And yes, they are basically all have sort of their labels in terms of of of severity, I would say probably most commonly used with the neuropsychologists that do formal cognitive testing would be called the dementia rating scale. And there there are specific numbers that that, you know, get labeled with formal cognitive testing.

Dr.Toenjes
Right.

Dr. Koren
And cardiologists and neurologists work together all the time and kind of bounce things off of each other, because often in the cardiology realm will be dealing with vascular or cardiac reasons for people having strokes in a stroke is usually relatively obvious, although sometimes I'll turn to my colleague and say it's kind of something funny going on here. Can you help me figure out if this is a neurological event or not?

Dr. Koren
And then some more subtle things like people that are just not functioning as well and whether or not there's a connection between what's happening from a cardiovascular standpoint and a brain standpoint. So is agitation just mentioned? Dementia is really, you know, a severe form of brain functioning that's not allowing people to do their basic, basic daily living activities.

Dr. Koren
And one of the first things we do is try to figure out what's causing it. What's a long issue? And from a cardiovascular standpoint, we'll talk a lot about are there blood clots from the heart or from the blood vessels that are going up and causing problems in the brain? And when that happens and we can prove that's the case, we call it vascular dementia, meaning that there's some piece of clot or plaque or cholesterol deposit that's actually causing some mechanical damage to the blood vessels that are affecting the brain.

Dr. Koren
And then there are other categories that don't seem to fall into this vascular dementia category. And that's and that's where we would then would transfer that patient over to the neurologist to look at things a little bit more critically.

Dr.Toenjes
And I think that it would be helpful to consider somewhat the history of the way things get labeled the reason. And you'll still hear patients when I ask, well, what what's been told to you is the cause for the cognitive impairment in your loved one. And the answer is they just have a dementia. Historically, neurologists and physicians in general have not gotten to sophisticated about labeling the etiology.

Dr.Toenjes
And so just a nonspecific dementia is something that has been commonly the diagnosis.

Michelle
Or just kind of like an umbrella, correct?

Dr.Toenjes
Yeah, with no real differentiation between different causes of dementia. And the reason for the majority of that, at least with the most common cause of dementia, which would be Alzheimer's disease, you know, there's largely not been disease modifying therapies. And so what's the need to really differentiate something that historically has been best diagnosed at autopsy? But as as our scientific knowledge in the in our society as a whole, move forward with putative and hopeful disease modifying therapies, it starts to become very important to try to decipher exactly what is the cause of this person's cognitive decline and is it something that we may have some sort of treatment for?

Dr.Toenjes
And so it is important now to not just generally use the term dementia if you're trying to ascribe an etiology and come up with therapeutics, it's starting to become much more important to label the etiology like vascular dementia. The second most common cause of degenerative dementia is Lewy body dementia, and there are obviously other etiologies as well.

Michelle
So back to Lewy Body. What exactly is that? I know my stepdaughter, they said she doesn't have Lewy Body, but because she was fainting and having some like episodes like that, she's in her young twenties, but they already said she doesn't have this. How how do you get to that point?

Dr.Toenjes
So Lewy body dementia is is a at least pathologically a very different dementia from Alzheimer's disease. It's in the class of disorders. We call this synuclein apathy. A lot of the pathologies and explanations for the different degenerative dementias and involve precipitation of certain abnormal proteins or substances within neurons or around neurons of our brain. In quite simply, the way they've been described through the years is how the pathologists see them.

Dr.Toenjes
And when you see Lewy bodies, which are pathological entity that you see on a microscope, which is contained of alpha synuclein in just the right areas of our brain, that is the pathological entity of Lewy body dementia. The clinical presentation or or disorder of of Lewy body dementia has some unique hallmarks that do very much differentiate it from Alzheimer's disease.

Dr.Toenjes
Typically, there will be very prominent and early visual hallucinations. The type of cognitive decline. It's a little bit different than an Alzheimer's disease patient in a Lewy body. Dementia patient will have very commonly associated other disorders like a REM sleep behavior disorder, potentially even many, many years before the onset of the cognitive decline. So it's distinct clinically.

Dr. Koren 
So much of what we do in diagnostics nowadays is is based on imaging, are able to just distinguish these different types of dementia, dementia based on imaging at all.

Dr.Toenjes
So imaging is going to appropriately be split up between anatomical imaging like C.T. And MRI based imaging where you see literally just the structure of of of brain tissue. And then there are additional modalities such as pet imaging, where we're looking at the amount of glucose metabolism per volume, brain tissue. And then there are specific ways to radio labeled pathological entities such as beta amyloid, which precipitates in a number of disorders and phosphorylated tau, which both of those actually have FDA approved SPECT ligands.

Dr.Toenjes
You can use.

Dr. Koren
That clinically.

Dr.Toenjes
Not so much in in while it's available and you could you could obtain that someone would be paying out of pocket for it. It's quite expensive. So it's still in in reality and in use as basically limited to research studies. But you can actually you can also do dopamine transporter imaging that's aspect imaging that we do actually use sometimes and that can help tease out Parkinson isms and Lewy body dementia.

Dr.Toenjes
Being at one of the Parkinson isms could theoretically be helpful in certain situations, but usually that's that's not necessary.

Dr. Koren
You start to do a biopsy and make a definitive diagnosis.

Dr.Toenjes
You wouldn't you wouldn't, you would if that were going to change your management. But it's the presence of it's really not going to change the management. And so no, not at not at this time. We don't get too sophisticated. We stick with clinical criteria to diagnose something like a Lewy body.

Michelle
Is is there treatment for dementia that can reverse it or is treatment just to kind of maintain it?

Dr.Toenjes
So in terms of treatments, it I think is very helpful to split up treatment into different general categories. The first category would be symptomatic relief, and the second category would be disease modifying, meaning changing the course of the illness. In historically, we have had basically symptomatic relief therapies and we're we believe in the research world that we're on the brink of disease, modifying therapeutics, which.

Dr. Koren
Is really exciting.

Dr.Toenjes
And so you have some of some of the therapies for the various dementias will will be thought of as symptomatic relief. And there are many patients that do achieve benefit from the medications that are available. I would point out that I say repeatedly in the clinic that that while there are some controversies and and and we're on the brink of hope for, you know, disease modifying therapeutics, there are disease modifying approaches and there are a number of things that significantly influence the rate of decline for various dementias, specifically Alzheimer's, for sure.

Dr.Toenjes
And those things are are the things that your your doctors are always telling you to do, basically live live a healthy lifestyle, control your blood pressure, remain physically and mentally active, sleep appropriately. Right. Sleep apnea, treat it, things like that.

Michelle
Right. And with over XYZ and with over 6 million Americans believed to have Alzheimer's disease and it's the sixth leading cause of death in the United States. Those are some some big factors to consider. You know, and any doctor you talk to is going to say sleep, eat well and move.

Dr. Koren
And that leads me to my session ending QUESTION. All right. I get that honor this time.

Michelle
Okay? Yeah. Yeah. How about you, Dr. Warren?

Dr. Koren
So is is dementia inevitable? Is everybody going to get something of some cognitive impairment as they get older and it's something that we inevitably deal with? Or are there people who have absolute no signs of it at advanced ages?

Dr.Toenjes 
That's that's an interesting thing to be worried about.

Michelle
Yeah, right, Right. And we are going to do that.

Dr.Toenjes
And lean.

Michelle
Back in the next segment.

Dr.Toenjes
This guy maybe. But there are there definitely have been folks in the medical literature and and intelligent people that who have had the thoughts that you know, a pathology or a process, something like an Alzheimer's is not necessarily a pathology, but a component of aging. And and, you know, in that respect, you you would you would conclude that potentially you're destined to get that particular disorder if you live long enough.

Dr.Toenjes
Now, that may be 110. When you start to develop Alzheimer's, that might be 47. And so anywhere in that frame, you know, that sort of pathology and then the sequelae of the pathology may unfold. But there are there really are people who are at advanced ages and they have a a remarkable absence of of the types of pathology seen in Alzheimer's and for some reason, they also do not have vascular changes at those ages.

Dr.Toenjes
And it's interesting to note that those patients memories will be just as good at 100 as it was.

Dr. Koren
Sign me up for those genes.