What If Dementia Risk Is Half Choice?

Alzheimer's gets talked about like a lightning strike. The science says otherwise.

Dr. James Galvin from the University of Miami breaks down what the evidence actually shows about dementia prevention — and why nearly half of your risk may come down to choices, especially ones made in midlife.

We cover the biology without getting lost in it: how amyloid builds up decades before symptoms, why some people never develop cognitive decline despite brain changes, and what that tells us about resilience and brain reserve. Plus the risk factors you'd expect — sleep apnea, high blood pressure, diabetes, inactivity — and a few that might surprise you, like hearing loss and social isolation.

Then we get personal. Dr. Galvin walks through the "N of 1" approach: a personalized brain health strategy built around your history, behaviors, and function — not a one-size-fits-all plan.

🎧 Subscribe, share this with someone you love, and tell us — what's the one change you're ready to make?

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Transcript

Medical Disclaimer And Introductions

SPEAKER_00 0:00

This podcast shares insights, not medical advice. Please consult a professional for your care. Hi everybody, this is David, and today we're joined by my co-hosts, Dr. Karen Gilbert, and Dr. James Galvin. Dr. James Galvin joins us from the Comprehensive Center for Brain Health at the University of Miami, where he leads the Division of Cognitive Neurology and directs the Louis Body Demention Research Center of Excellence at the University of Miami Miller School of Medicine. He is one of the leading experts in Alzheimer's disease, dementia prevention, and precision brain health. His research has shaped how we understand modifiable risk factors, lifestyle interventions, and the emerging world of the personalized N of One prevention trials. He has published extensively on how Alzheimer's develops over a lifetime, why prevention is possible, and how Taylor plans can delay or even avoid cognitive decline. Dr. Galvin's work gives families something rare in this field, evidence-based hope. So, Karen, would you like to ask Dr. Galvin the first question?

Can Alzheimer's Be Prevented Or Delayed

SPEAKER_01 1:18

Tell us your thoughts on whether we can actually prevent Alzheimer's or delay the development of Alzheimer's, giving us more quality years of life.

SPEAKER_02 1:33

And thank you for that very nice introduction. So that's a great question. And, you know, I would say the answer is yes, but it's a qualified yes, right? Because we're still learning so much more. Um we know a lot about risk factors that are both modifiable and not modifiable for Alzheimer's disease. Um and it's important just to keep in mind there are some things which we have no control over. The greatest single risk factor for these diseases is age. Um and until we find a fountain of youth, there's really no way to change that, right? Um another non-modifiable risk factor is sex. So women are at a higher risk for Alzheimer's disease, men are at a higher risk for Parkinson's and Lewy body dementia. Um and then family history, because we can't control our genes. So even though most cases are not genetic based, the fact is that you get risk genes that you inherit from your parents, and if they have a lot of diseases, then you have a higher risk of having some of those same diseases. But I think what people don't realize is that there are a lot of modifiable risk factors. Um there's reports and you know, they they constantly add new ones, you know. But you know, I would say there are 20 or 30 things that, you know, are associated with the risk for Alzheimer's disease. Um, and those risk factors altogether may explain almost half the total risk, which means that if you could make some modifications in your lifestyle, um, in reducing your risk factors, controlling medical conditions, um, doing all the things that doctors have told you to do forever that we often don't do on our own, we could significantly change the risk of developing these diseases. And if you have problems, the evidence suggests that you could actually slow the progression of the disease.

SPEAKER_01 3:26

Well, and and David's proven that, uh, which he's very open about. Having been given a diagnosis of early stage Alzheimer's, he literally started to reverse his symptoms by adopting so many of these strategies. So uh, David, I'll hand it to you.

Amyloid Biology Versus Lifestyle Reality

SPEAKER_00 3:46

You've said a lot about big risk factors, don't work through amyloid or tau. So what really matters more, lifestyle or biology?

SPEAKER_02 3:56

I would say they're both important, right? Because but and they're not mutually exclusive. So we know that amyloid deposition in the brain begins maybe 20 years before people develop symptoms. And we know there are some risk factors that increase the probability of amyloid depositing. So traumatic brain injury seems to be associated with amyloid deposition. Poor sleep habits, particularly the loss of slow wave sleep, which is our deep, deep sleep. So people who have sleep apnea or other types of problems, that seems to be associated with amyloid deposition. But a lot of other risk factors, not so clear how they're associated with amyloid or with tau deposition. Um, and so I think there are there's an expression, all low, all roads lead to Rome, right? And so you can start from anywhere in the Roman Empire and you can get to Rome by following a Roman road. Um, there are a lot of roads that lead to Alzheimer's disease. There's the amyloid road, but it's not the only way to get there. I think that there we have to be mindful of amyloid, but there are a lot of other things that we can do to try to preserve our brain. And the most important evidence for this is that if you look at cognitively normal adults who pass away and come to autopsy, about 25 to 30 percent of them will have Alzheimer changes in their brain, even though they never manifested any symptoms. So, amyloid, while everybody has amyloid who has Alzheimer's disease, not everybody who has amyloid will have symptoms. And so these other factors, lifestyle factors, controlling medical conditions, may play just as an important role as amyloid in developing the symptoms of the disease.

SPEAKER_01 5:46

So that's a concept that I find a lot of people don't understand, that you can actually have the pathology, but you might have not you might not have symptoms. So everyone comes to you with a unique set of variables, their genes, their age, their gender, uh where they lived, the type of work they did, exposures they might have had, whether or not they have metabolic diseases, diabetes, high blood pressure, metabolic syndrome. So I'm glad to see more of a trend toward personalized medicine because we don't have a one-size fits all in so many things.

N Of One Precision Brain Health

SPEAKER_01 6:33

So you have this concept of a sample of one, N of one, when you're looking at prevention. Can you tell us what that looks like for someone coming to you with perhaps emerging symptoms that they're concerned about, maybe someone else noticed or they noticed in themselves?

SPEAKER_02 6:52

Yeah, I mean, you use some of the butt words that I'll use as I'm describing this. But you know, if you've seen one patient, then you've seen one patient because each person's unique. They start on their journey in unique ways, um, and their journey progresses in unique ways. And so the concept of an N of one basically means that each person that we're doing things with is, well, we're not doing experiments on people, but each person's their own experiment, right? Um, they have their own unique risk factors. Now they may have risk factors that are similar to other people, but they have their own unique risk factors, they have their own unique lifestyle, they have their own unique family history, right? They have their own unique, you know, health beliefs, they have their own unique behaviors, right? And so when you think about this, each person's different. Each person's gonna respond to medications different, each person's gonna progress at a different rate, each person's symptom presentation may be different. So if you take a one-size-fits-all approach, it really fits no one. You're basically trying to shove a lot of round pegs into square holes, hoping that you'll find a round hole. And I don't think that that's the way to approach medicine. I think you want to look at each person as an individual and think about what's the best thing for that individual person. And that takes more time than a one-size-fits-all approach, but I think it's a more effective approach. And we have evidence for this. So, cancer, for a long time now, has done this concept of precision medicine. Now, in cancer, that means they take a little piece of a tumor and a biopsy and they then study it and they look for all the different markers. And then they design the chemotherapeutic regimen based on the markers that are expressed. Now, you've seen TV commercials for some of the newer medicines, and they say, you know, if you have this marker and this marker and this marker, but if you're negative for this marker. That's precision, right? By knowing everything you can about that piece of tissue, you can design medicines that will shrink that tumor. Well, why can't we do the same thing for the brain? Now we're not going to take a piece of the brain, but we can look at that person and all their individual risk factors, their resilience factors, their comorbid medical conditions, their lifelong course, their family history, and say, okay, how could I design an approach that's going to be the most effective for you as an individual rather than just grabbing something off the shelf? And this is the same I do for everybody.

SPEAKER_00 9:27

That that to me, that's not a smart way of approaching the So do you do this with every patient, or do you pick and choose, or they decide how they want to want to go through this particular N1 program?

SPEAKER_02 9:37

So

What A Personalized Workup Includes

SPEAKER_02 9:38

everybody that comes to see me, we do it as an individual. Now, you know, it requires a little work on the patient's part, right? So before patients come to see me, they get a little packet. Well, if not a little packet, they get a pack of papers to complete. It's 56 pages long. The reason for that is I don't have then I don't have to ask all those questions while I'm sitting in front of you. You can fill them out ahead of time. So there's a section that the patient completes, and then we also have someone come with the patient. We call a patient advocate, can be a spouse, an adult child, it could be lots of different people, uh, but someone who knows the patient well and they fill out a section of what they've observed. And then we put that all together. And when the patient comes in, you know, I interview the patient, I interview the family, we do a neurologic exam, we do neuropsych testing, so we do memory testing, and we do a full physical performance evaluation. And then we put that all together so that we can best understand all of those different aspects of what's going on with the patient, and then design something that's more tailored to that patient. Now, I may prescribe the same medicine, different people, because I don't have, you know, there aren't that many medicines available, but all the other things we do would be more tailored to that individual.

Midlife Risks That Matter Most

SPEAKER_00 10:53

If someone is in their 40s or 50s, what are the top midlife changes that make the biggest difference later on?

SPEAKER_02 11:02

So it depends on the studies that you've looked at, but you know, the Lancet Commission was uh basically a group of investigators led by Jill Livingston, basically looked at the literature and identified, you know, originally 10, then 12, now 14, and I'm sure they'll be adding to that list of potentially modifiable risk factors. And what was interesting in midlife, the two risk factors that had the greatest impact, one was diabetes, which is not surprising because diabetes can cause lots of things to lots of people, but the other was hearing loss. And so hearing loss explained about 7% of the risk of developing Alzheimer's disease. People would say, well, I've never really thought about that, but the fact is that that's the case. There are other risk factors: air pollution, social isolation, high cholesterol, low physical activity, obesity. There are many of them. And then but there are risk factors that are not on that list, right? So traumatic brain injury, as I mentioned before, it's a risk factor. Uh, smoking is a risk factor. So there are lots of factors out there. And so, again, that's why we want to collect all of that personalized in information, because one person's set of risk factors may be very different than another's. And so our approaches to reducing risk, it's going to be different. Likewise, there are resilience factors, right? There are things we know that make a stronger brain. So higher education and occupational attainment, right? So not just the years of school, but what you do with that, right? So you could have a high school education and be the CEO of a company, or you could have a PhD in astrophysics and live in your grandma's basement and play video games, right? So one may have a higher attainment in education, but actually doing less with their brain than that person who has eighth grade, eight years of education, but runs a multinational corporation, right? So you want to look at that, right? You want to look at how physically active they are, how socially active they are, how cognitively active they are. What do they eat? Um, do they practice mindfulness, right? That's living in the moment, uh, experiencing the world as it's coming with you, uh, having an optimistic look on life and not letting the weight of the world bear down on you, right? So we know that these things build a better brain. These are resilience factors. So if you look at the risk factors, the resilience factors, and then you look at the things that people are doing on an everyday basis. If you have diabetes, are you managing your diabetes? If you have high blood pressure, are you managing your blood pressure? Because if you're not, your brain's gonna suffer for that, right? And then what kind of healthful behavioral changes can we institute, right? So if you're gonna go ride a bike, wear a helmet, right? You know, if you're gonna drive a car, wear a seatbelt, right? So, you know, if you were in an accident and you didn't have a helmet on or you didn't wear a seatbelt, you'd have a lot more injuries to your head and the rest of your body than if you wore those things, right? And so again, it's each individual. We want to look at them as an individual. And while some things are common sense I would tell everybody to do, it might be very, very uh tailored to that person's individual

Resilience Habits That Build Brain Reserve

SPEAKER_02 14:13

risks.

SPEAKER_01 14:13

I always fear that people don't appreciate how many things they can do that can really make a difference. Dental care, preventive dental care, is now being recognized as a healthy approach. In other words, don't ignore your dental health because that puts you at risk. Uh, so that's a new field now where the dentist is important to us. Many of the things that uh we've mentioned as risk factors create inflammation in the body, which we know is a risk factor for autoimmune diseases, vascular disease, cancer. And now we believe cognitive disease as well. So, where do you see the research going? You know, for so long it was let's get the amyloid plaques removed from the brain. And there are treatments that have done that, but they don't dramatically change the course. They're not cures, they don't necessarily stop the process, they may slow it, but they haven't produced, you know, what some people might have wished would be a cure. So what do you think is on the horizon? What will research look at going forward?

Why Treatments Are Not A Cure

SPEAKER_02 15:31

So let me address this cure thing, because this this is this is a bug to me, right? So everybody wants to look for a cure for Alzheimer's disease, and they say, well, I have medicines and I'm not curing it, so they but you know, we don't use them or I don't want to take them. Doctors don't cure disease. Doctors treat disease. No one's ever been cured of their diabetes, no one's ever been cured of their osteoarthritis, their hypocholesterolemia, their hearing loss, no one's ever been cured of their cataract, no one's ever been cured of any of those things. You can remove things, you can have surgical approaches, but you haven't gotten rid of the problem that caused it in the beginning, right? But if you take medications, you're better. Alzheimer's no different. Why put Alzheimer's or any other dementia on a pedestal that you don't put other diseases on? So we have medicines that have symptomatic benefits. People who are on medicines progress slower than people who are not on medicines. That's true for the old medicines, the cholinesterase inhibitors and mementine, and that's true for the new medicines, the monoclonal antibodies. People who are on medicines progress slower than people who are not on medicines. Now, we'd like to see more effect, and I think that's where all of these other things come into play, right? Because if you build a good substrate, then you're likely to see better effects, right? If you have someone who has uncontrolled diabetes and has high blood pressure and is overweight, is not physically active, is socially isolated, is not wearing their hearing aid, right, who falls down a lot and injures themselves, what kind of response might you see with the medicine? Whereas if you take that same person and you control their diabetes and you give them a hearing aid and you control their blood pressure and you have them lose weight and they become socially and physically active, then you're building a better substrate for those medicines to have an effect. With that said, more research is needed, right? We need research on, we need more research on these lifestyle factors, but we also need more research on medications, and they're gonna go hand in hand. You know, again, I hearken back to other diseases like cancer. If you have lung cancer and you get treated for your lung cancer, but you keep smoking, you know, you're probably not gonna do real well. If you have Alzheimer's disease, you're getting treated for Alzheimer's disease, you don't take care of those risk factors, you're not gonna do as well. If you take care of the risk factors, you'll do better, but it's not a it's not a cure for the disease either. So if you set the stage where people are doing brain healthy activities and you give them appropriate medicines, you might see a bigger response. We have medicines that address amyloid right now, but Alzheimer's is a complex disease. So, like all complex diseases, it's probably not going to be one medicine. Almost no cancer is treated with a single medication. HIV is not treated with a single medication. Why would we think Alzheimer's disease would be treated with a single medication? So there's research, there's over 160 clinical trials testing over 150 different agents, only which about 25% address amyloid. So there's lots of things in clinical trials that are addressing all the other aspects of the disease. And I think at some point down the road, we will have for Alzheimer's disease what HIV has for AIDS, which is heart, high anti-retroviral therapy, or what cancer has for just about every cancer, which is a protocol, a cocktail, a bunch of different medicines that address different parts of the tumor pathology. I think we're gonna do the same thing for Alzheimer's disease. You'll have an anti-amyloid drug, an anti-Tau drug, an anti-inflammatory drug, a growth factor to try to, you know, regenerate cells that are that are injured but not dead yet. I I think these are all things that are gonna come into play. And that's what's really exciting. That's what keeps me going at the end of the day, is that there's active research. Well, I hope there's active research. You know, it's a little hard with what's going on with uh research funding at the moment, but there's active research going on by lots of smart people at lots of different places who have lots of different ideas. And that someday you'll see a confluence of all those ideas that'll lead us down the

Future Research And Community Action

SPEAKER_02 19:51

correct.

SPEAKER_01 19:51

We hope with Alzheimer's Community Care and what we do in the community that we're we're helping that in in the sense that we're trying to inspire people to know what those modifiable risk factors are and be inspired to do all that they can, as you say, to build that substrate to have their diet, their exercise, their hearing, their dental care, not smoking, having those things in the best shape possible. And should they encounter uh a situation where they're experiencing cognitive impairment, you know, they already have those aspects in in as good a shape as as they can be. It it can't hurt. It's nothing bad can happen from adopting healthy lifestyles. There shouldn't be any scary side effects. There can only be benefits, and that might help them for anything they might face health-wise going forward. So we have a huge problem. We have the CDC says half of US adults have high blood pressure. In addition to the 30 million known with diabetes, there's another 90 million at risk for developing type 2 diabetes, and only half of them know it. So uh, you know, getting this word out and having people focus on controlling those conditions, preventing or trying to reverse them should they begin, uh, as many of the healthy lifestyles as they can adopt. It it certainly can't hurt.

SPEAKER_00 21:24

Is there anything else you want to add, Dr. Alvin?

SPEAKER_02 21:27

I think that we can't do this alone, right? We need partners like Alzheimer's Community Care, with other disease associations, with uh community leaders, because it's it's it's a village and not any one person, one center, one doctor is going to be able to do this, right? Um, and so the more help we get, the more help I get, the more likely we are to benefit a bigger number of people, right? Um I'm limited to how many people I can see. Um, but if I can give knowledge to people and they can spread that knowledge to other people, we can make a significant impact and change the face of this disease. Our goal here at the Comprehensive Center of Brain Health is you know, build a better brain, build a better you.

SPEAKER_00 22:13

Dr. Galvan, thank you for sharing your time, your expertise, and your heart with us today.

Final Takeaways And Share Request

SPEAKER_00 22:18

Your work reminds us that Alzheimer's isn't just something we wait for, it's something we can actively push back against with knowledge, action, and personal care.

SPEAKER_01 22:28

To everyone listening, there are steps you can take. Sometimes we say what you do in midlife might help uh prepare you for your brain's health in late life. If uh this conversation gave you hope or gave you a next step, please share this episode with someone you love and care about. As always, keep learning, keep asking questions, keep fighting for brain health. Thanks for joining us. We'll see you next time.

SPEAKER_00 22:55

We are here on this earth as humans to help others. That's what I believe. Please note this podcast provides information only. Podcasts should not be considered professional advice or a substitute for professional advice. Viewers of the speakers do not necessarily reflect those of Alzheimer's Community Care or David Ufelder. Listeners and viewers are encouraged to consult with appropriate professionals and are responsible for how the information provided is used.