SPEAKER_00 0:00

Your brain is your body's control center, shaping how you think, feel, and move. When something goes wrong, it can affect everything. Welcome to Your Brain, Your Health, a podcast from St. Luke's Neurosciences. We'll explore conditions that impact the brain, spine, and nervous system and how they connect to your overall well-being so you can stay informed and take charge of your health. Thank you for joining us on today's episode, Alzheimer's Disease, Memory Loss, or something more. I'm your host, Dr. Eric Eustace, emergency medicine physician at St. Luke's University Health Network. And with me today is Dr. Daniel Ackerman, Section Chief of Neurology and Director of Stroke and Vascular Neurology here at St. Luke's. Together we're going to talk about Alzheimer's disease, what you need to know, and why so often it's misunderstood. And Dan, welcome. Thank you for being here. We're so excited for you to talk about this common, I'm assuming pretty common disease.

SPEAKER_01 0:55

Alzheimer's itself is actually very common, and trouble with thinking and memory or concern about trouble with thinking and memory is even more common. I think all of us are worried about it to one degree or another.

SPEAKER_00 1:07

I think it's a fear that probably most people have in the back of their minds of am I going to get this debilitating disease and how is it going to affect our loved ones? So we'll dive right in. So what actually is Alzheimer's disease?

SPEAKER_01 1:20

Aaron Ross Powell So first of all, that comes back a little bit to what we talked about in our episode on brain health with the difference between dementia just overall and certain causes for dementia. So again, dementia I would characterize as trouble with memory or thinking or both that's significant enough that it messes with your life from day to day. Now, Alzheimer's disease is one specific cause for dementia. This is what we call a neurodegenerative disease, meaning it's damage that builds up in the brain over time. In this case, that damage happens because of misfolded proteins. There are two in particular. One is a protein called amyloid that is involved in a bunch of different things. It's found in the body, but there is a certain type of amyloid that can clump up and form plaques in the brain. The second protein is tau. And tau, when it gets a bunch of phosphorus on it, becomes these tangled strands. We call them neurofibrillary tangles. And in that state, those plaques, which are amyloid and the tangles which are tau, they get stuck. The brain can't get rid of them. And it's kind of like have you ever seen those commercials or television shows about yeah, commercials I'm showing my age, right? We don't have those anymore. They don't exist. Have you ever seen those reels where they show what's happened like in the home of someone who's a hoarder? Yes. Right? And it just builds and builds, and then the camera comes in and it's this like horrific scene, right? And you're like, how did that even function? Well, that's kind of what's happening to those neurons in the brain. These proteins are building and building and building until those nerves just can't function anywhere, they end up dying. What we would call primary dementia, neurodegenerative diseases, like Alzheimer's disease, are related to a misfolded protein. And the disease itself and the symptoms of the disease come down to which proteins are misfolded and what part of the brain is being damaged or impacted. And that's what produces the symptoms we talk about. And because there's so many things that can impact thinking and memory and cognition, even for people who do have Alzheimer's disease, it's not always the whole story. People can have Alzheimer's disease and have other things going on affecting thinking and memory as well, which is part of what makes it complicated. But but in terms of like biologically, what is it? What's going on? That's that's what's going on.

SPEAKER_00 3:33

Okay. So I unfortunately my grandmother had Alzheimer's pretty bad, and then I had uh uh an aunt who had Lewy body dementia. And um, you know, I'm always wondering what will I get this? Or maybe that's an irrational thought. Are there genetics like is it predestined that somebody has the genetics to eventually get Alzheimer's disease? Or is it a combination of both genetics and lifestyle factors? And what are the risk factors and how does somebody develop that in in terms of their life, so to speak?

SPEAKER_01 4:07

So, first of all, no, you are not predestined to get it. So that okay, just take a deep breath, relax, you'll be okay. Um I will say it is very rare for, again, this is the difference between a genetic predisposition and an inherited predisposition. So there are genetic forms of Alzheimer's disease. Um those are caused by specific genes. They happen very early in life compared to people who get more typical Alzheimer's disease. They often have an extensive family history of people with Alzheimer's. So uh with regard to the specific genes, we don't have to go into the little monikers for the genes here, but um, for most people who have symptoms of Alzheimer's, they do not need to be tested for those genes.

SPEAKER_00 4:51

Okay.

SPEAKER_01 4:52

If they don't have an extensive family history, they haven't gotten it when they're exceptionally young, um, that's that's really not likely. That being said, yes, it is the case that if someone has a family history of Alzheimer's disease, they may be more likely than the general population. And there are some other genetic factors that are not all on their own enough to say that someone is definitively going to get Alzheimer's disease, but they may increase someone's risk to a degree.

SPEAKER_02 5:20

Got it.

SPEAKER_01 5:20

Now, importantly, this is not something we just screen everybody for for a couple of reasons. First of all, if someone has genes that make it a little more likely for them to get Alzheimer's disease, it's not a foregone conclusion they ever will. You can scare the heck out of people by doing these genetic tests. And, you know, people can even, you know, is there a risk of someone being discriminated against when we're talking about their job or talking about uh things like health insurance and disability insurance and life insurance based on some of those tests? And there are laws that are meant to help protect that to a degree, um, but also it's a growing field, it's an evolving field. The pillars of brain health we talked about last time are crucial for preventing Alzheimer's and preventing dementia overall, regardless of those genes. So it's not like the treatment we recommend is necessarily going to change. So that's why we don't screen people genetically. Um, often when you look this up, you find age is the biggest risk factor. Um it's kind of a misnomer. It's not that getting older itself is a risk factor. It's really more that, first of all, people who are no longer aging, if someone has passed away, um, well, they're they're not going to get it, right? Um and so the proportion of people with Alzheimer's uh is higher when we're older. And also we are much more cognizant of the symptoms. When you look at it statistically, we would say that um, you know, in the U.S. there's roughly 7 million people with Alzheimer's, but that number is expected to continue to go way, way, way up. And you know, when you look at people in that sort of 65 to 75 range, it's only about 5% of people that may have it. But when you go from 75 to 85, you're up at more like 13, 15 percent above age 85. We're thinking up around 30 percent, so like one in three. But remember, it's not just a matter of Alzheimer's disease is not something like so this is not something like we would see in the emergency room, like, you know, either there's a giant gash on the arm or there isn't. Right. You know, either someone's having a heart attack or they're not. Let's not have any of that. Um, even if someone has the Alzheimer's pathology going on in the brain, the degree that the symptoms are happening and how much it impacts them is going to be very unique to that person. So even these numbers you have to take with a bit of a grain of salt.

SPEAKER_00 7:35

Aaron Ross Powell Talking about symptoms, um you know the most common thing I think people think about is memory loss. But I've heard sometimes that there's other symptoms associated with the disease. Um what are those symptoms?

SPEAKER_01 7:48

Aaron Ross Powell So as as I'm fond of saying, the brain gets its dirty little fingerprints on every system of the body. And all of our behaviors, our perceptions, our understandings are r related to that. So, you know, breaking this down first of all, with regard to memory, um, yes, it tends to be more short-term memory that's impacted, and and long-term memories tend to be spared. Although that's very common overall. Um, and particularly as we're getting older, it's very common that our short-term memory and particularly our ability to pay attention um is limited a little bit. So that all on its own doesn't tell me someone's got Alzheimer's disease. Okay. Um over time, Alzheimer's can affect things like speech and language, our ability to understand language, our ability to produce appropriate language. Um decision making and judgment can be really impaired. Remember, this isn't just about memory, it's about thinking. Our ability to make appropriate decisions, interpret and understand situations and the like. Insight can also be impacted. And by insight, what I mean is our ability to understand that something is not going right. And that's actually one of the aspects of Alzheimer's disease that is the scariest, I think, for some folks. And that's also what creates such challenges at home. We are accustomed to looking at the world around us and and thinking about things, and we sort of take for granted that the way we perceive and remember things is the way things actually are. And as you develop Alzheimer's disease, that might not be the case. But patients don't realize that. And it's actually a symptom of the disease. It's not that they're not trying, it's not that they're not paying attention, it's a symptom. Um there can be changes in uh sensation, how we interpret sensations, including vision. Okay, how do we interpret scenes in front of us, changes with mood and empathy, social, uh social interactions, that sort of thing. All of these things can shift to one degree or another. When you do cognitive testing, it's not just a memory test, right? We test uh we test several different aspects of memory and figure out like you know, is memory, is short-term memory okay, but there's issues with decision making, or issues with language, or issues with calculations, or issues with attention? Um, you test each of those a little bit differently to get a picture of how they impact somebody.

SPEAKER_00 10:07

Okay. You mentioned cognitive testing. Is that the only way that Alzheimer's is diagnosed to actually do a formal test on an individual? Um Are there certain brain scans that some somebody would do? How do physicians diagnose Alzheimer's disease in patients?

SPEAKER_01 10:24

So at this point, the most important tests are cognitive tests. Okay. Okay. Um Alzheimer's is not diagnosed based on a scan. And importantly, we don't use scans to screen people who are asymptomatic. Okay. Just like what we were talking about with some of those inherited genetic tests. Um, could we do a boatload of scans and figure out what proteins are doing what in the brain to a degree? But does it necessarily mean that a person is going to absolutely get Alzheimer's disease and and can we treat that a certain way? Not necessarily. So, really the first and most important testing is a combination of a uh really detailed history and physical exam, including cognitive testing to one degree or another, based on someone's suspicion at that point. There are two things that you do. Number one is rule out mimics for Alzheimer's. Other things that are going along, going on physiologically or in the brain neurologically that might present symptoms like Alzheimer's, but actually be something completely different.

SPEAKER_02 11:26

Okay.

SPEAKER_01 11:27

Um and then there are some tests we can do. There are there is a specific uh scan or two, not an MRI, that doesn't tell you. And I'm a neurologist, I love a good MRI, but I just but that's not going to do it here. Um But uh, you know, there are some specific scans we can do to prove that someone has Alzheimer's pathology in the brain. You can do a test called a lumbar puncture where you get some spinal fluid because the the fluid that surrounds the brain and spinal cord is this special place in the body and it doesn't exchange things with our bloodstream. So a blood test doesn't always tell you. However, now we also actually do have blood tests that will help us to figure out if someone has Alzheimer's pathology in the brain. And so we and by Alzheimer's pathology I mean the changes in the brain that happen because of these misfolded proteins.

SPEAKER_02 12:13

Okay.

SPEAKER_01 12:13

So diagnosing Alzheimer's is really a combination of someone having a history consistent with it, they don't have mimics for it, their examination and cognitive testing is consistent with it, and we have proven they have actual Alzheimer's pathology going on, they have actual Alzheimer's changes going on uh in the brain.

SPEAKER_00 12:34

Aaron Ross Powell Are there treatments that we can give patients for Alzheimer's?

SPEAKER_01 12:40

Yes. Okay, anything else? Um No, so the answer is yes. There's actually uh there's actually three main modes of treatment for Alzheimer's disease, all right. First of all, you remember all those other symptoms that we talked about, right? The mood symptoms and different things so those can be treated with a combination of medicines, number one, and also lifestyle changes. So uh changing the way our day is organized, developing habits. So habit is your brain's friend. Your brain, for all the amazing things it does, your brain is kind of lazy. And if it can get by doing something by habit, it's gonna want to do that. And so habit sort of takes a little pressure off of your brain. And by developing habits that help you to remember what you're supposed to be doing or where you're at or what's going on, um signs and things that reinforce uh what's going on around you, those things can help. Um, the second type of treatment is more specific treatment for thinking and memory. There are a few medicines that we use that are meant to help sharpen some of that thinking and memory. They're not they're not amazing, but they are legitimately helpful. But in both cases, what we've talked about so far are things to treat symptoms. There are a few specific treatments for Alzheimer's disease now that are what we call disease modifying, or in other words, although they are not cures, they actually can slow down the progression. So someone who is diagnosed with early, and and you have to use these early on, someone who's diagnosed with early Alzheimer's disease through the process that I talked about before, um, there are specific treatments that we can use to help slow down that progression. So importantly, these new treatments um they do slow the disease down, they do not treat the symptoms. So someone on one of these new treatments is not necessarily going to feel better from day to day. That's what the other stuff is for. Medicines to treat mood, to sharpen memory, to help with energy, to help with sleep, to all of that sort of stuff. Okay. That's actually how we treat the symptoms. These other medicines, people who are receiving them, they will get worse over time. Um Alzheimer's is a progressive condition, so they are going to get worse over time, but they will get worse more slowly, and they will have more time that they are still themselves and acting more like themselves and behaving more like themselves compared to someone not receiving these medicines. Trevor Burrus, Jr.

SPEAKER_00 14:57

Are there any misconceptions about treatment that you've heard over the years?

SPEAKER_01 15:01

I think there are a lot of misconceptions out there. I think, first of all, uh again, coming back to this idea of dementia and Alzheimer's kind of being interchangeable and that they're sort of the same thing. Um secondly, the idea that if someone has Alzheimer's, that's the only thing they have that's impacting their thinking or their memory. A lot of people can have multiple things. Um, the idea that it is completely untreatable, right? Um I think some of the biggest misconceptions, however, are people who are convinced that they have it or people who are convinced that they don't. Right. And that can go in both directions. Again, it's something we all worry about, and that's appropriate. But uh that's where we really do have to involve our medical team and be willing to engage in some of that testing and figure out it's not going to be perfect. It's not like a blood test that comes back and gives you a level and and this is your Alzheimer's level, doesn't work that way. This idea that, oh, well, I don't I don't want to check it because what if I have something and there's nothing they can do anyway? Well, that's just not true.

SPEAKER_00 16:01

I think you mentioned, Dan, that you know, early detection is key, right? A lot of these treatments that you mentioned need to be started early in the process. And we've talked about that on this podcast before that it's important to be upfront and transparent with your provider and your physician to make sure that you're addressing these issues and having real conversations, right? It's difficult. No one likes to talk about these things, but we have to talk about them to be able to help and treat them.

SPEAKER_01 16:29

So exactly. For these newer treatments that slow things down, we are slowing down the rate that damage is building up, not necessarily stopping it, but we still can't reverse that damage. So once the damage is done, that doesn't mean we can't do anything. We can still work to treat symptoms. It's hard, it takes time, it takes effort. We can still work with that, but we can't get that back. We can't get those brain cells back once they're once.

SPEAKER_02 16:54

Time is brain.

SPEAKER_01 16:55

Gosh, as it turns out, time is brain, isn't it? Your favorite catchment. I've heard that somewhere before. You know that's my license plate.

SPEAKER_00 17:01

I I didn't want to mention it on the podcast, but that's all right. I'm not telling anyone how I spell it, so it's you know You know, we have obviously listeners that have either they live with somebody who has Alzheimer's or they know somebody who has Alzheimer's. Uh what things can they do to help support somebody or a loved one who has that disease?

SPEAKER_01 17:21

Aaron Ross Powell Well, first of all, importantly, there's no one intervention. When we're talking about Alzheimer's, it is truly uh it is truly all about everything in your lifestyle, right? There's no one thing you can do that is super supportive or one thing you can do that is completely catastrophic. Um there are, however, some great principles to follow. Yeah. Um first of all, I would say we don't have enough time to go into all of these things, so I would go to the Alzheimer's Association website. That's a patient-facing website where uh they have a lot of good advice about what to expect and what to do and what have other patients and families done. There's no perfect playbook here, and each family is figuring this out as they go. Um so understanding what questions you should be asking, what symptoms to expect, and and which ones can be treated is big. So using that website or Alzheimer's support groups uh as a framework to figure out uh some of those things is very important. Beyond that, I would say, again, recognizing this is not just a matter of somebody not paying attention or not wanting to understand or not being willing to understand. So pick your battles. It is not necessarily the case that you have to push somebody every time they get something wrong, but you don't want to let things go completely. It's coming up with that balance to maintain peace in the home, but also to make sure that we're giving people the support they need to help exercise and push their brain.

SPEAKER_02 18:51

Yeah.

SPEAKER_01 18:52

Um, creating uh a supportive environment for people and a safe environment. And that includes, remember, people with Alzheimer's can have sleep disturbances. So how is someone sleeping? Are they getting up in the middle of the night? Are they by themselves, considering whether or not it's still safe for someone to be driving? And that's something that uh we actually have a fitness to drive testing program at St. Luke's that we use, and um again, that's not a there's not a single perfect measure, and nobody wants to give up driving. Yeah. Um, but nobody wants to cause an accident. And I will tell you, because Alzheimer's, again, impact your ability to perceive that there is something wrong, you can be the most careful driver in the world. You only go short distances during the day, familiar places. Don't get me wrong, those things are helpful, but it doesn't mean everything's gonna be okay. Um so being willing to have that conversation with your loved ones and and with your physician. Um and uh for some people I do recommend they consider devices that can be helpful. For example, um whether we're talking about watches or phones, but devices that have GPS enabled, so if somebody is is lost or is confused or something, there is uh a way to find them. Uh devices that are organized in a very simple way with single push-button connection to loved ones so that it's not something that's confusing, or if someone is a little out of sorts or stressed, they can get in touch. Um and I love devices that have automatic fall detection, so that if someone is, you know, we want people to be as independent as possible for as long as possible. And using devices where if a person is out walking or something, if they were to take a tumble, which of course we we of course want to prevent, but we want people exercising, right? That's one of our four pillars. So um, if they were to take a tumble, the device will detect that and contact the family, contact an ambulance, this sort of thing. Um there are commercial devices that do this, there are uh there are devices that are intended for healthcare that do this. Um and that's also where, again, looking uh working with your uh physician or clinician that knows Alzheimer's and has some of those resources, or using the Alzheimer's Association website things to get uh get that stuff working out.

SPEAKER_00 21:03

Support, there's a lot of support out there, it seems like for families and patients and utilize that is sounds like your advice.

SPEAKER_01 21:11

So Alzheimer's is common. We hate that. We want to make it go away, but at least again, it means that there's a lot of light shed on it. This is a shared experience that people have, which means you don't have to go through this alone.

SPEAKER_00 21:22

Yeah.

SPEAKER_01 21:22

And even though, yes, each family, each individual is is separate and unique, um, but there are things we can anticipate and things we can help with.

SPEAKER_00 21:30

Aaron Ross Powell Is there anything else that you want the public to know about Alzheimer's or any myths out there that you want to dispel?

SPEAKER_01 21:36

Aaron Ross Powell Beyond the things we've already talked about, again, it's really just a matter of be willing to have the conversation.

SPEAKER_00 21:42

Yeah.

SPEAKER_01 21:42

Be willing to talk early about it, recognize that not every lapse in memory is Alzheimer's disease. Okay. So things that are quite common as we get older can include distractability. And by distractibility, the way that manifests itself, and I'm going to scare you a little bit. It here, okay. But the way that manifests itself is you walk into a room and forget why you went in there. You put something down, it disappears off the face of the earth. You uh you know, you have a conversation, you lose track of it in the middle, you know somebody's name or know somebody and and you it's just not there. Those are very common symptoms as we get older. They do not necessarily portend Alzheimer's disease. Still, the question is how much of that is okay and how much isn't? Yeah. Right. Now I'm willing to bet you've had some of those experiences. Sure, I think we all have, yeah. I know I certainly have. That's a regular Monday for me, my morning. Oh good to know. So next Monday, you and I will sit down.

SPEAKER_00 22:45

We'll forget this conversation ever happened. No.

SPEAKER_01 22:47

No, so we'll record this again next week, or it's good. Um but but again, recognizing that those symptoms, it's not that we shouldn't pay attention to them. We should. But we should recognize that a degree of that is normal and to be expected. It's okay to still talk about it with your clinician and to measure it and figure out are we still in a place where it's okay and to keep up with it over time. Where I get worried, okay, when people start to tell me things about um different social behaviors, issues with decision making, trouble doing things they know how to do. Like if I forgot how to tie a bow tie, that would be a problem. I would need some serious cognitive therapy for that. Um people where their trouble with thinking and memory starts to require a lot of compensation, family, friends, others.

SPEAKER_02 23:38

Yeah.

SPEAKER_01 23:38

Um people who are worried about their thinking and memory, and as a result, they're not being social, they're not going out, they're not having conversation, even if it's not a problem. Like that doesn't mean there's a real issue necessarily, but when we isolate ourselves, when we limit ourselves, that becomes And that would make things worse, I'm assuming.

SPEAKER_00 23:59

Exactly. Like we need social connection, we need to be able to um have that outlet.

SPEAKER_01 24:04

The other thing that, and this is controversial, and a lot of people are gonna not like me for saying this. I don't think it's controversial. I just think people are not gonna like me. You gotta take care of your vision and your hearing. Yeah. And when people tell you you're not hearing me, you gotta get it checked. And when people tell you your vision isn't that, you gotta get it checked. Your brain is trying to perceive and understand the world around you. And when it has to work harder to do that because the vision is off or the hearing is off, that plays a big role in the kinds of symptoms. When we're treating someone, even someone who has Alzheimer's disease, um, and they have dementia or cognitive trouble. One of those treatments is to make sure they have appropriate hearing assistive devices and that their vision checks are up to date, this kind of thing. It can be legitimately helpful. All the people who argue back and forth about this, they're gonna play this part of the episode for whoever they're gonna be.

SPEAKER_00 24:57

Yes, I would have never thought that though. That is that I think that's a a very good point because I've never heard that before. Those two things could be linked or could affect things a little bit more.

SPEAKER_01 25:08

They can they can really make a big difference symptom-wise. And and there are things that are testable. Um it's it's something that I mean, memory testing can be difficult. Thinking testing can be difficult. It's not hard to test your hearing in most cases. Right. It's not hard to test your vision in most cases. And no one wants to be stuck with expensive different glasses or hearing aids or whatever. Um, but there's a lot of a lot of couples in particular who, you know, there's one of them is a little more obstinate saying, no, it's fine, I'm fine, I can hear everything fine. And that goes on for like however many years until they see me in the office and we settle that argument and I get in trouble, either with my patient or with their loved one, or both.

SPEAKER_00 25:48

I think um, you know, being both physicians, we really want patients to be honest with us. And that is key. The more you let us know when things are off in any capacity, the the better we can kind of manage that and at least assist. Aaron Ross Powell When you go to your physician and your doctor's office, uh making sure that you're letting them know if something's off. Whether that's vision, hearing, memory, whatever it may be.

SPEAKER_01 26:17

So well, and thankfully with the electronic medical record, it does create some good ways to communicate with your physician as well. Um aside from having to call the office and maybe wait on hold and talk to someone and then talk to another someone, to be able to just send a message and say, right when you're right when you're concerned, doesn't matter what time it is day or night, right when you're concerned to send a message and say, Hey, this just happened. I'm worried about this. This just happened. Is this okay? And your your clinician might write back to you and say, Yeah, that's all right. Yeah, fine, but at least then you've asked the question.

SPEAKER_00 26:49

Yeah, St. Luke's my chart. I mean, that is it's it's beautiful. It's been it it really changed the game in how we communicate with our provider.

SPEAKER_01 26:56

So absolutely. And I don't have to take a day off of work to call the office and wait on all exactly.

SPEAKER_00 27:00

Well, Dan, it's been a pleasure. Uh, thank you so much for talking to us about Alzheimer's disease. That's it for today's episode. You have your brain, your health. Thank you for spending your time with us, and you we hope you're walking away with some clear insights of how to prevent and treat Alzheimer's disease. As always, until next time, thank you very much. Take care. Your brain health matters, so keep learning and listening. If you found this episode helpful, share it with someone you care about. And for more resources on brain health, visit St. Luke's Neurosciences at SLUHN.org. Until next time, take care of your brain and your health.