How to Talk to Patients and Families About Monoclonal Antibody Treatments for Alzheimer Disease (What Matters)

Join Dr. Michael Harper, Professor of Medicine at the University of California, San Francisco; Dr. Halima Amjad, Associate Professor in the Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine and Dr. Lolita Nidadavolu, Assistant Professor in the Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, as they discuss How to Talk to Patients and Families About Monoclonal Antibody Treatments for Alzheimer Disease (What Matters).

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Transcript

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Michael Harper 0:00

Hey, hello and welcome. My name is Dr. Michael Harper. I'm a professor of medicine at the University of California, San Francisco. I'm pleased to be moderating today's podcast, which is part of American Geriatric Society's new educational curriculum, Alzheimer's Disease, New Technologies and Treatments. We design this curriculum to support both experienced clinicians and geriatrics fellows as they navigate the rapidly evolving landscape of Alzheimer's disease diagnosis and treatment. As new technologies and therapies continue to emerge, it's more important than ever to stay informed and prepare for the future of dementia care. I'm really excited to be speaking today with Dr. Halima Amjad, who is an associate professor of medicine at Hopkins, who's also a PhD in clinical investigation, and is a former junior investigator of the year for AGS. She's joined today by Dr. Lolita Nidadavalou, who's an assistant professor at Johns Hopkins, and she too has a PhD, and hers is in molecular genetics and biochemistry. They are the authors of our module titled How to Talk to Patients and Families About Monoclonal Antibody Treatments for Alzheimer's disease. So we're going to be spending some time talking with them about this subject, kind of going a little bit deeper. Encourage you to check out their module as well. And I want to welcome you both. Great to have you here.

Halima Amjad 1:11

Thank you, Dr. Harper. We're excited to talk about a tough topic.

Michael Harper 1:15

So I think a good place to start would be to, since I've never had any of these conversations yet, I would love to hear your experiences and some of the background when it comes to having these kinds of conversations with patients and their care partners.

Halima Amjad 1:28

Sure. So I'll start and then I'll have uh Dr. Lolita Nidadavolu jump in as well. So as you kind of got from the introduction, we're both geriatricians and researchers who are relevant to this conversation. We serve as dementia specialists at the interdisciplinary Johns Hopkins Memory and Alzheimer's Treatment Center. I've been seeing patients there for about the past 10 years or so. And what that means is that in the last two years, we've been having active conversations with patients and families about monoclonal antibody treatments, thinking about whether it's an option for the patients that we're seeing and kind of walking them through risks, benefits, and what treatment entails. I know that I personally have a handful of patients who are actively receiving therapy or completing the 18 months of Lecanemab therapy. I also have a lot of patients who have chosen not to pursue this treatment or for whom it's not an option after we have discussions about it. But Lolita, if you wanted to share kind of what you've been seeing and doing with your patients in clinic as well.

Lolita Nidadavolu 2:29

Sure. Thank you, Dr. Amjad. So I've been an outpatient provider at our memory clinic for the past year. But prior to that, I was working on inpatient consult services at our main hospital. And so identifying patients that were being brought to our consult service who had memory problems that could likely be due to Alzheimer's disease and referring them to a site where a lot of these discussions were taking place and really kind of setting the stage for some of those initial conversations. And so now I'm a bit more involved, obviously, at some of the later stages of these discussions. I too have a few patients that have elected to pursue treatment with both Lecanemab and now Donanemab, but also have some patients that when having had these conversations at the end of the day, they and their families have elected to not pursue them as well.

Michael Harper 3:18

So we have conversations all the time with our patients about that various treatments, whether it's for Alzheimer's disease or not. What's particularly important about this conversation?

Halima Amjad 3:27

Well, I think the way you ask that question, I think to me gets the idea of right, shared decision making is really like the heart of geriatrics. We do it for everything, even for decisions patients might be making where the scientific evidence really goes against what they're deciding or what they're thinking about. But I think with these treatments, it truly is a shared decision for all patients. And that's really because the evidence supporting treatment is gray and there really isn't a single right answer. I think we're all aware that there are trade-offs with potential for real risks and potentially small benefits. So for all patients, there is a choice to be made and a discussion to be had if it's an option for them. And I think that's why this module is important. And I think as Dr. Nidadavolu and I were talking about this topic in general, we were just thinking about the fact that it's so important that clinicians realize that how they engage in the discussion, the words they use, how they frame it, influences the patient's decision. And kind of acknowledging that influence that we have, I think really is why we need to think about how we have these discussions.

Michael Harper 4:36

I guess when you think about this, like we all sort of have an idea of how to do in general shared decision making. But are there some general principles that you can help that clinicians can use to guide these conversations?

Lolita Nidadavolu 4:45

Yes. And so I think some of the key, the key things to consider is ensuring that you have enough time and all the important decision makers for a particular patient in the room when you're having these conversations. And I think another aspect of that should be kept in mind with all parties that are participating in the conversation, is that there really is no right or wrong decision to be made when deciding about whether to pursue monoclonal antibodies for Alzheimer's disease. And, you know, really reminding yourself that can be a good approach when at the outset of these conversations as well. Another thing that is really important, especially as we are getting more uh more data from the current research that's still being done on participants from studies and trials that are kind of extending beyond the initial endpoints for these major studies that have been discussed in some of the other modules, is that we have our own views and biases that may also color the ways that we're we're we hold shared decision-making conversations. And so a key aspect of addressing that when we're having the shared decision-making conversation with our patients is to really be honest and transparent about our own views and biases, all the family members and patients that we're discussing this with as well. And so one way of doing that can be to provide different perspectives, such as opposing views, and also focusing on more of the objective evidence and data that is available while also emphasizing what's not known can be a good place to start when providing those other perspectives with patients. And the other thing to really keep in mind, as is true with any shared decision-making conversation, is really being open to patient preferences as well as family preferences and patient values while you're you're leading these discussions with them. And another key thing to remember that can also be related to your own bias or views about these treatments, is to make sure that you're discussing these treatments and have discussions with anyone who's potentially eligible to make sure that you're not including bias or to try to minimize bias as you're having these conversations and also to promote equity in terms of accessibility to these newer treatments as well. A key way of doing that is really incorporating it into conversations with all patients who have a diagnosis of Alzheimer's disease, you know, again, tailoring the conversation based on patient preferences. And so we can go into more detail with that in some of the next questions.

Michael Harper 7:21

So I think that's really helpful to sort of have that initial sort of framing of how to at least approach this. This doesn't sound like this is a short conversation, is my is my guess. So what are some ways to kind of get this dialogue going? You get a referral for someone. I think in your module you described this share framework. I was wondering what you could tell us about that and maybe how you use it.

Lolita Nidadavolu 7:41

You know, for the sake of the module, I think we wanted to have providers that may not be familiar with this type of shared decision making have a specific framework that we can go through step by step to help guide them as they go through these conversations. However, the share framework is one of many that are available for um for providers as they're they're have engaging in shared decision-making conversations with patients. So to some extent, um, this is maybe one way of sort of formalizing what we what we may do in ourselves in clinic. I personally don't uh strictly adhere to the share, the individual share components, but I think this is a good summary of the key aspects that are brought up in the discussions that I personally would have with patients. And Dr. Amjad, if you want to also chime in whether you use the SHARE framework yourself or not.

Halima Amjad 8:34

Yeah, I think on that side, and you know, I think even in medical school, right, there were people who loved acronyms. I was never a big acronym person, but I think for me too, I incorporate all the principles of these kind of shared decision-making frameworks. But I don't know that I, you know, systematically go in that order, right? It sometimes depends where the decision takes you, you know, where the conversation is taking us and sort of that free flow of the conversation rather than going kind of step by step and oh gosh, I forgot I skipped a step, let me go back, but rather having a more natural conversation with patients and families.

Lolita Nidadavolu 9:09

Yeah, and especially for for patients that you've been that we've been seeing in clinic for some time, you know, we've had we've had other visits in which we've been able to uh assess patient values and preferences. So to some degree, um while we're having these uh more formal conversations in the clinic uh specifically about the monocolonal antibody treatments, we can, you know, allude back to other other conversations that we may have had to help with guiding us.

Michael Harper 9:38

I kind of agree with you. The framework is more and more important than the actual going through a process step by step. It's a little more organic that way. But I'm curious to know, um, I thought the idea of seeking input from our patients is something maybe we don't always do as much as we should. I was curious to know what you think about how important that is, particularly in this context of a new treatment for which a lot of information is still not well known in terms of you know long-term outcomes, for example. What kind of input are you seeking from your patient and their care partners?

Lolita Nidadavolu 10:06

Yeah, that's a great and really important question in terms of guiding the rest of the shared decision-making conversation. and so one of the first things I actually will ask patients is if they've even heard anything about these newer monoclonal antibody treatments for Alzheimer's disease. And often patients or their family members will mention other friends or family members that they know of who have started treatment or they'll have mentioned um, you know, commercials or just talking with other other friends about and their their peer network, you know, telling them about this. Often there's also family members who are reading the latest published literature, and so they're they will sometimes seek to participate in the conversation by being the ones to bring it up in the first place, especially once we have more definitive data that's suggesting um Alzheimer's disease as a primary etiology for someone's memory loss. So um, Dr. Amjad, I guess just from your experience since you've been at the memory clinic a little bit longer than I have, by seeking where a patient's at in terms of their understanding of these treatments being available, whether they have people in their peer network or families that are currently taking it, can help kind of set the scene for these conversations. Um, Dr. Amjad, if you don't mind chiming in on some of what you've seen in your work.

Halima Amjad 11:23

Yeah, so I think I definitely will ask people if they've heard about these treatments or read about them. Some people haven't. Some people have very strong thoughts on what they've heard about it, that they've heard there's a new treatment and I should ask my doctor about it versus, oh, I read about horrible side effects, right? So getting a sense of what they know already. But I think there it's also important. And I try to kind of couch it in this like, okay, now we have this diagnosis of MCI or early stage dementia due to Alzheimer's. Let's, you know, let's discuss a treatment plan, because one that does also open it up for discussion of other treatments. But then that idea of how do we introduce this discussion and the fact that there is a decision to be made. So there I think we'll say that there are FDA treatments now available or recently approved for Alzheimer's disease, but there's some controversy or lack of consensus about the risks versus benefits. And I wanted to talk about it with you and your family to see, you know, if you might be interested or not in pursuing the treatments. Cause I think there it's that idea of like, again, there is a decision to be made. It's not you had an MI and here's your aspirin, right? It is grayer. And so just opening up that idea of like we need to discuss risks and benefits and then kind of jumping into the details.

Lolita Nidadavolu 12:36

Yeah, I think a key thing to also consider when you're again at at this initial stage of the conversation is really emphasizing that this is the decision that needs nuance, it needs time, it needs time for people to talk to other important decision makers in their lives. We won't immediately have a concluding decision, you know, in terms of next steps at the outset of this conversation.

Michael Harper 13:01

So I'm sure one of the things our patients and our care partners are going to want to know is if I take this drug, what's it gonna do for me? And I think as clinicians, we probably have differing opinions about that. So I imagine it's challenging. How do you try to put the results from the clinical trials into a language and context that our patients and care partners might be able to digest?

Halima Amjad 13:28

Yeah, I would say there, I mean, we do share, like I will use specific numbers and some of the data that we have available, but to the way you asked that question, right? Then it's kind of putting it in that big context, right? So there I will always tell patients and families that we know from the clinical trials that these drugs remove amyloid plaques from the brain quite effectively, but that the impact on cognitive and functional decline is modest or small, where I'll actually explain to them that the clinical impact isn't what we would expect to see if amyloid was the sole cause or the sole story behind Alzheimer's. I do share that number of, you know, that we see of the oh, it there's a delay of about five to seven months or a 20 to 30 percent kind of slower decline over 18 months. We're saying that, you know, someone who's receiving treatment, they'll be kind of five to seven months behind someone who wouldn't have been receiving at the end of 18 months. But there, I couple it with the fact that we don't have long-term data beyond those 18 months really yet. And that five to seven months, I find helpful to put it in the context of Alzheimer's is a disease that people will live with for a long time. So even 10 to 15 years, where for some people they'll say, I'll take, you know, even that small improvement. But some people, or for example, if they have family experience with Alzheimer's, will kind of see, like, oh, that's not that big of an impact. And then I think the other really important piece there is just sharing that the treatments are not curative. So I'm always very clear is like these don't stop progression. Patients will still decline. I often find myself like using my hands and showing them like a slope, and right, it doesn't flatten that slope that you still do experience changes.

Lolita Nidadavolu 15:14

Yeah, I'm finding often um when I'm having these conversations, we have a lot of older adult patients coming to our clinic that have many of the comorbid conditions that were not necessarily explicitly stated or considered in some of those original studies. And so um often that lack of knowledge about their specific situation or case is another factor that will be discussed, you know, during these conversations that, you know, in terms of safety or efficacy, you know, we we may not necessarily have all the information that we would like to have, at least as of now, you know, to help in these decision-making.

Halima Amjad 15:52

I think too, the other piece that certainly I know geriatricians often talk about, right, is the impact similar to done. And so there I will tell patients, right, that the magnitude of benefit kind of on paper cognitively might be the same, but sort of say that these drugs, I will often say might be disease modifying, right? That the Donepezil type drugs, cholinesterase inhibitors, we don't really think that they're disease modifying. And there, as Dr. Nidadavolu kind of pointed out, I'll often bring up that there's differing opinions. So I'll say, you know, the pharmaceutical companies, right, they're very excited that we're having this benefit versus there are other people who will say that's such a small benefit, it's not meaningful, and kind of explain this spectrum and those differing opinions that people will see. And I will share kind of where I and my colleagues fall on the spectrum, where I think even that is different, right? Institution to institution and even specialty to specialty, where I'll often tell people that, you know, my colleagues at the memory clinic, we all kind of fall in between. We're not, oh, this is for everybody, but we're offering it, right? For select patients and having these discussions about the medication.

Michael Harper 16:57

So that's the potential benefits. How do you talk about the potential side effects? I mean, we we use the term aria. That can't be too scary. I have friends whose kids are named ARIA, right? But obviously, there's more than just sort of a finding on an image, right? It really accounts, it really means there's something going on in the brain that's potentially scary, swelling and and bleeding. So, how do you talk about the side effects?

Halima Amjad 17:23

Yeah, so that's often obviously a big part of the conversation outside, right? What does the medication do for me? There's that concern of it might do this for you as well, and it's that small benefit. So there, I mean, will you spell it out, right? What is ARIA? It's amyloid-related imaging abnormality that in the process of removing amyloid plaque, right, that it can lead to areas of swelling or bleeding in the brain. There, I think what words we use matter, right? Because saying bleed versus microhemorrhage or a smaller, you know, small area of bleeding, it's important. I'll usually say, you know, small areas of swelling or bleeding in the brain, but it's the brain, right? It's an important organ where sometimes I'll say, right, it's not a small bleed on the skin is different than a small bleed in the brain. But then while after introducing kind of what aria is, I will share specific numbers. And that's where actually for me, I try to get as specific as I can, which means that once we have APOE4 status, I will, like before a memory clinic appointment, actually, you know, pull out the New England Journal or the JAMA paper and the tables to say, like, you know, your risk of ARIA E or ARIA H is, you know, this exact risk because right, we just have the overall, you know, 22% or 36% for the drugs versus what is that individual person's risk. So I will share that information. I will share the rates of symptomatic ARIA, right? So the people who have symptoms is much lower. Then I'm also, I make sure I mention that there have been some deaths, right? And now we're getting more real world data, but I'll share that both in the clinical trials and open label extensions that there were a few deaths and right. And that for some people, that's a big deal, right? For some people, they'll say, oh, it was only, you know, three to six deaths, and it's not as, you know, that they're, you know, more, I would say, kind of focused on the benefit. But I make sure to mention all of that. And then I think that's where too it's important for us to take into consideration other risk factors, right, that the person might have, right? Are there things that we don't have in the data that we think that they might be at a higher bleeding risk? I think that's where institutional protocols come in, right? We have sort of a cutoff for how many micro hemorrhages, right? Where there's some people who's like, whoa, whoa, I think your risk of a hemorrhage is going to be even higher. Or for me, I know for people that I think are at a high stroke risk, but they haven't had a stroke, right? Then I'll think, kind of talk to them about, you know, I'm worried about your risk of stroke. And you can't get TPA, you know, you can't get the treatment for an acute stroke were it to occur. And I think that's something that, you know, we really need a clinician to help um connect the dots. And of course I'm biased, but I think geriatricians are best positioned to do that.

Michael Harper 20:03

The last thing I want to ask on this particular subject is so we talked about potential benefits, we talked about the potential side effects. Then there's also just the process, right? Of what it takes. What do you talk about in terms of frequency of treatment, frequency of monitoring? How do you talk about that?

Halima Amjad 20:18

Yeah, so there, I mean, I think there we know kind of we have a set protocol that we're able to share that our clinic is using of right that they are going to have more clinic visits, the, you know, whether it's monthly or every two week infusions that take, you know, you're gonna be at the infusion center for at least an hour, but probably longer. And then I think the other big piece is explaining just the number of MRIs that they'll need to have. Often they need a new baseline MRI, and then they're going to need four to five MRIs over the treatment course and thinking about, you know, the time it's gonna take for them to get there and um, you know, get the treatments and the MRIs done. Um, you know, thinking about, I know for some people it's like the needles, right? There's needles involved that that makes it um more involved as well, and just thinking about right transport to and from. So we do walk them through everything that's um involved um in in treatment. I think the one piece that for us hasn't come up as much in conversation that of course had a lot of hype when the drugs first came out was the cost piece. So I would say there, because most patients are Medicare and they're covering a bulk of the cost, that hasn't been as much of a discussion. But I think the the time commitment, the monitoring, we do walk them through what they would need to do. And that's often something that will also give it to them in writing so that whether it's before we have this conversation or after, they can look through everything in more detail to then, you know, weigh their decision carefully.

Michael Harper 21:46

I appreciate that because I think there's so much that's involved in this. This is not just taking a pill, this is not just getting a once-a-year infusion. This requires a lot for our patients and their care partners to sort of consider. When that's all said and done, I imagine that as experts in this area, you might get asked the question, so Doc, what would you do? How do you respond to that?

Lolita Nidadavolu 22:09

This is a question that we we often get asked when we get to this point in the conversation where we've gone over the risks and benefits. Again, I think this is a key question that will tend to come up with patients and their families, um, especially when they realize that, again, there's not a clear right or wrong decision to be made regarding monoclonal antibodies for Alzheimer's disease. And one of the key ways to help guide them through this decision-making process is really being as transparent as possible with what your own biases are or preferences that you have to help guide them to making the best decision for them. Again, being transparent, being honest about your biases with your patients and their families is a really important way of addressing that question of, you know, what do you think I should do? Also, I think a key way of addressing your own biases is outlining why others who may have a different opinion to what your bias is, you know, and communicating why they may make a different recommendation or decision with regards to these treatments. I think that one way to help kind of respond to this question is helping the patients and their families put together and connect the dots between the evidence that you've given them, the clinical factors that can impart individualized risk or benefit for treatment, as well as incorporating their goals, values, and preferences, which again you've known and elicited from having a relationship with this patient and kind of conversations about this, about treatment and about Alzheimer's disease in the past with them. So often when I'm having this conversation, when I'm asked, what do you think I should do by the patient? I'll kind of turn it back to them and say, well, you know, we've gone over some of the risks, we've gone over some of the benefits for treatment based on past conversations that we've had where you've expressed concern about you know X, Y, Z side effects, or wanted to express a desire to perhaps, you know, undergo any available treatment as long as you met criteria to be able to do so, kind of talking also also about some of these individual risk factors, such as having adequate social support, to be able to make it to the many MRI scans and or to make it to the many infusion visits, to be able to have help with transportation or monitoring for any symptoms. That I can sometimes will reframe the question to try to help them put the pieces together to be able to get some sort of consensus at the end of the conversation.

Halima Amjad 24:45

Yeah, I think Lolita, well, I'll add to that too. I think it is just that piece of like, right, trying to think of like, you know, what would you recommend for this patient? You are their clinician who's helping them make this decision. And there again, I think it's important to as much as we can look at the data and what we know and don't know because we all bring those biases. So if it's someone who, you know, doesn't have a lot of other comorbidities, they don't have a lot of vascular disease, you know, they're truly MCI, not kind of teetering on moderate stage, we're all saying, you know, I don't see a lot of risk factors that would put you at, you know, a higher risk of side effects. I think this is a reasonable treatment option to consider. But there I'll often tell people, like, right, that idea of it's okay if you don't, right? That it's not a cure. But if you are interested in pursuing it, I think it's a reasonable option for you. Versus some people will say, you know, it is technically an option, but you have a decent amount of vascular disease on imaging. So I worry that your clinical benefit might be smaller. Um there again, it's obviously there's an art to it. And again, that's where I think it's also just important for us to realize like the influence that we can have on the decision. And so trying to be, as you said, kind of transparent. That's where I just share my thought process and then let them, you know, obviously ultimately make the decision.

Lolita Nidadavolu 26:00

Yeah, and I think just to echo again what what Dr. Amjad just said, you know, the way that we organize and and frame the discussion can really impact the takeaway that the patient and their families from this. So again, that's why having some sort of framework, you know, whether it's share or something else, can be a good way, you know, you want to make sure that the patients are really taking away the key information, both both for benefits and risks, and also have have a sense of that more personal, again, it's all about the personalized approach because you know, many of the patients that we're seeing who may be eligible for for treatment, you know, are not, you know, necessarily the same demographics or you know, have the same medical comorbidities as the individuals that were in the in the large studies that were were done initially looking at these. And so that's a key clinical interpretation that that'll need to be done for all patients that we're having this discussion with.

Michael Harper 26:55

I imagine that you've probably had cases or maybe you haven't, but could imagine a patient or a family member who's really motivated. They come in, hey, I read about this, I want this. This sounds like, you know, we've been searching for something to do for this. But it turns out for one reason or another, you think they're either they're not clearly eligible or they're just not a great candidate, or either at high risk for side effects. How do you have that particular conversation?

Halima Amjad 27:20

Yeah, so I think there, one, if you're in a place where there's an institutional protocol, that's an easy thing to lean on, right? That, you know, you're too advanced or you've got six micro hemorrhages, right? Um explaining that, right, that one is that, you know, we we wouldn't be able to offer the treatment, but there too, right? Knowing that someone could just go somewhere else and find someone else who'll give it to them, I think it's still important to explain why, right? So is it the risk is too high for that individual or that, right, the studies don't show benefit when someone is moderate stage disease. I think those are where that I tend to write, rather than emphasize um, you know, oh, it clears amyloid plaque, emphasizing that we know amyloid's not the whole story or the fact that it's not a cure to kind of provide that reassurance that you're not missing out on a miracle drug, right? I'll let people know that there's controversy, you know, around it as well. And then I think they're the other important piece that honestly, even we sometimes lose sight of when you're in this like depth of the conversations about these specific treatments are here's all the other things that we can do, including, right? Oh, cholinesterase inhibitors, the magnitude might be kind of similar to these drugs, talking about, you know, the non-medication strategies, lifestyle factors, and really focusing on those pieces. Because I think the other reason people come looking for it is because often they're just told by other providers that there's not a treatment. And so if you frame it as here's alternative treatment, there's here's other things that we can do to support your loved one that that that makes a difference.

Michael Harper 28:56

Yeah, it seems like the message has to be this is not an option for you, but we're still gonna take care of you. I think that seems like the thing we want to sort of communicate. I'm gonna wrap up, but I want to sort of give you an opportunity. Um, since you've had experience having these conversations, what's sort of the sort of broader insights and lessons you may have learned?

Halima Amjad 29:14

One, I think something we already talked about is gosh, it takes a lot of time. This isn't usually a one-time conversation. There's some setup for it in advance or information shared over time. This is where we're often adding in video visits because it's easier to accommodate, you know, having that discussion outside of time in the clinic and then bringing them into the clinic if they've decided, okay, now I'm going to do treatment and let's move forward. And on that side, I also don't want people to feel pressured. So I don't bring them in for their, you know, pre infusion visit before we've had a kind of in depth conversation. But I think that's where it's just recognizing that it needs time. And do you have the time, right, to give to this important conversation? I think the other interesting piece just has been seeing kind of where patients and families. Fall both pre-discussion and post-discussion, that people really are, you know, all along that spectrum of their values, preferences, and the decisions they make, which is why I think it's important that we have the discussion with everybody and not make assumptions, right? There's people who I think are going to go for treatment and then they decide not to. Then there's the people who, you know, oh, I saw my father live with this disease. I know there's risks, but I want to do every little thing. I think the other piece that's I've found interesting is that many patients have said they understand this these aren't miracle drugs, but they're hopeful that if it slows things down a little bit, something will come out later that they could still benefit from. And so that's just kind of a general sentiment. I know, you know, multiple patients have brought up.

Lolita Nidadavolu 30:45

And again, I'll just echo what Dr. Amjad said. I think the key, I think, when having these conversations is again kind of going in a bit open-minded about what the patient and their families will decide. Because I too have been surprised. I think I've seen some patients where, you know, again, looking through things and, you know, and they're imaging the ApoE status, you know, like, okay, well, maybe they could be a reasonable candidate to have some benefit from this treatment. And then, you know, just based on their understanding of the risks and benefits or what they themselves have read or you know, personalized experiences from family members or friends, they elect to not proceed with the infusion treatments. But again, the the key thing is really, you know, emphasizing that there's still is a lot that can be done. I think some of the patients that I've had conversations with that haven't been eligible, you know, again, have a lot of vascular risk factors. And so really focusing some of the conversations during our memory clinic visits on addressing some of those vascular risk factors, talking about exercise, talking about practical ways that they can kind of incorporate some of these lifestyle modifications because that can be beneficial to brain health and heart health and just overall function, can be another way to also again make make families feel like there still is as much that we can do to help with cognitive decline.

Michael Harper 32:03

Well, I want to thank you both for not only being here today, but for the module that you've contributed to this, I think, really, really important subject that all of us as clinicians, particularly primary care clinicians who are seeing these folks who we're gonna be the entry point to this discussion, right? And so helping us to begin to think about this framework, to think about the principles, to be able to think about how to put some of these uh outcomes into some sort of context that our patients can understand. And then to think about just how hard these conversations likely can be. And that maybe it's not just a single conversation. I think if I took anything away from this, this is maybe maybe multiple conversations that we have to have. And knowing who our patients are, what's important to them, and what matters to them seems to be really important. So thank you again for being here. Really appreciate it. And I want to encourage all of our listeners to go and take a look at their module. It's really, really great.

Halima Amjad 32:56

Thank you. Thank you.