70 Million And The Fight Against Dementia

What if you could find out you were developing dementia 17 years before you had a single symptom? That's not science fiction anymore and the doctor who built one of the country's most replicated dementia care programs says what's coming for baby boomers should concern every single one of us.

Dr. Cathy Lee sits down with Dr. David Reuben founding director of the UCLA Alzheimer's and Dementia Care Program, now operating across 34 health systems nationwide for a conversation about what's changed in dementia science, what's coming in 2036, and what you can actually do about it.

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Dr. David B. Reuben
Geriatrics
 
Dr. Cathy Lee
Geriatrics

The information shared in this podcast is for educational purposes only and does not constitute medical advice. Please consult a qualified healthcare provider for guidance specific to your situation

Transcript

SPEAKER_00 0:00

Half of my patients are I'm kind of the the closer. I'm the last few physician don't care for them. But the other half may get better.

SPEAKER_04 0:10

On this episode, Dr. Kathy Lee sits down with Dr. David Rubin, founding director of the UCLA Alzheimer's and Dementia Care Program, and he shares the revolution in dementia treatments and why what's coming for baby boomers should concern every single one of us. What's been your perspective of kind of just change in dementia?

SPEAKER_00 0:31

If you were to ask me this question 10 years ago, everything that you've seen in science fiction, we can now detect changes in the spinal fluid 17 years beforehand.

SPEAKER_01 0:45

Oh my gosh, so these primary care physicians have to start doing cognitive testing.

SPEAKER_00 0:51

The problem is that dementia is not going away. Baby brewers like myself are getting older. In 2036, they will begin to turn 90. And by the time you're 90 years of age, you have a lot of one to reach your dementia.

SPEAKER_01 1:12

So hello. I serve as chief of geriatrics there. And it is my pleasure actually to be talking with Dr. David Rubin today. So hi, Dr. Rubin. You have been a practicing geriatrician now for many years. I don't know if you want me to say how many years.

SPEAKER_00 1:39

Well, I've been practicing medicine for 45 years. Yeah.

SPEAKER_01 1:42

Yeah. And I know that we're not supposed to be listing credentials, but I did have to write it down because you have been the president of the American Geriatric Society, president of the directors of geriatric academic programs, chair of the board of the directors of the American Board of Internal Medicine, and then former chief of the Division of Geriatric Medicine at UCLA. So pertinent to our topic of dementia today, you're also the founding director of the UCLA Alzheimer's and Dementia Care Program. And I don't actually know much about the start of this program. So I thought it would be a great chance for you to tell me more about that.

SPEAKER_00 2:26

So it's a it's a story. I was finishing up some national responsibilities with the American Board of Internal Medicine, and when I finished, my email dropped in half. So I said, geez, I want to do something for UCLA because they were so supportive of me doing all this national work. And um one of my partner's patients had dementia, and uh both the husband and wife were his patients, and they were very wealthy. They were very wealthy. Uh but because I was division chief, if something was going on with her dementia, like a Friday afternoon at 5 o'clock, they would call me and say, you know, my caregiver is going out of the country to care for her family. How do I get another caregiver at 5 o'clock on a Friday? Um so he, when she got very, very ill, he wanted to do something for people who have dementia, like his wife. And he asked her just to go out and see what was available. And it turns out there was a program in Indiana uh that was doing very good dementia care, and uh, but it was in a safety net hospital. And so uh I talked with the people there and said, geez, could we adapt this to a hospital that sees um mostly private patients, UCLA? And um that was the start of it. Uh the patients um gave us a little bit of money. But even better, he introduced to us a f to a friend who had even more money uh and gave us our our first uh big gift, and we got started.

SPEAKER_01 4:15

Okay. So how did so it was more like looking for so connecting caregivers to patients or yeah, it's basically uh when somebody has dementia, um particularly if it's uh moderate or severe, we think about it as adopting them.

SPEAKER_00 4:36

And it's not when I say them, it's not just the patient, it's the patient and the caregiver. So it's a diad. And everybody's journey through dementia is unique. Uh and there's twists and turns and all sorts of plot twists that need to be addressed. So basically, the program assigns a nurse practitioner who's called a dementia care specialist who follows them, um, the the patient and the caregiver for the rest of their lives unless they enter a hospice or move out of the area or go to a nursing home. Uh by that point, there's not that much we have to offer them. But to keep them into the community, these dementia care specialists are are lifelines.

SPEAKER_01 5:27

Nice.

SPEAKER_00 5:27

So they're basically on call, like 24 hours or actually uh we we had to be respectful of their they have lives too. Um so basically what happens is uh from 8 till 5 they are um available for their patients. Uh the division of geriatrics has been gracious enough to take the nights and the weekend calls. Okay. But in in fact, they're very few. And they're very few because um the the patients and the family members are trained to call during the daytime. And most of the fires can be put out.

unknown 6:05

Okay. Okay.

SPEAKER_01 6:07

Um and then I know that there's been like caregiver training also, right? Like through this program.

SPEAKER_00 6:14

Yeah, there's uh caregiver training, there's referral to community-based organizations, uh, you know, what it c whatever needs to be done gets done. And we have a couple of social workers in the program, and um uh it's you know, whatever is broken, we do our best to fix. What we can't fix is the disease itself. Yeah.

SPEAKER_01 6:36

So what um like have there now been other people who have come to you and say, oh, you know, like can we adapt this program to other states?

SPEAKER_00 6:47

Yes, we have we have received a couple of grants, in fact, to promote dissemination. And we're in something like 34 health systems around the country.

unknown 6:57

Cool.

SPEAKER_00 6:57

So we're we're we're kind of all over the place.

SPEAKER_01 7:00

And in VAs too? I know I think that's a good idea.

SPEAKER_00 7:02

We are in uh one or two VAs. One I think is operational and one is still in preparation. Okay.

SPEAKER_01 7:10

Okay. Now you've mentored a lot of um other physicians, young physicians. So PhDs.

SPEAKER_03 7:17

Yeah.

SPEAKER_01 7:19

So I mean I think one of them is actually thinking of potentially trying to get it started at the VA. So David wants to. Right. Yeah. Wants to try and start it.

SPEAKER_00 7:29

That would be terrific.

SPEAKER_01 7:30

Yeah, for sure. And then especially with the model right there, too.

SPEAKER_00 7:34

Yes. We would be right there supervising and training and helping adapt it in the VA setting.

SPEAKER_01 7:41

Yeah. Um you gave grand rounds recently for internal medicine. And I remember we had talked before, um, and you had said that you were, you know, pretty excited just because there's now kind of more potential treatments for dementia. So um what's been your perspective of kind of just change in dementia, you know, kind of over time?

SPEAKER_00 8:02

You if you would have asked me this question ten years ago, everything that we've seen would have been science fiction. Yeah. We now understand the pathogenesis, the steps that happen on the route to clinical dementia. And we can now detect changes in the spinal fluid and perhaps in the blood 17 years beforehand. So things are going on, and that's where a lot of the action is right now, is to say, can we intervene when we see these changes and prevent the expression of these changes on cognition and functional status and the clinical syndrome of dementia?

SPEAKER_01 8:52

Right. So then I mean so then this is like before like even somebody is like in geriatrics potentially, right? Or is it you know what I mean? Like is it when like they turn 60 and then that's the time.

SPEAKER_00 9:09

Yeah, well that's that's a a superb question because when does it start?

SPEAKER_01 9:13

Yeah.

SPEAKER_00 9:14

Yeah. And if you think about it, uh this is middle to late middle life. Yeah. These changes start occurring. Right, right. And that's a lot of the interest right now. In fact, there are some clinical trials in progress now that take people in their mid-50s and they measure biomarkers, both in the blood and in the brain. Um, and they are beginning to test the effects of certain drugs in people before they have clinical symptoms. So that what they call them is cognitively unimpaired. So these are people like myself.

SPEAKER_02 9:54

Yeah.

SPEAKER_00 9:54

Uh you know, I could have one of these uh bad uh proteins in my blood, and uh but I'm still working, I'm still, you know, I've got a good life.

SPEAKER_01 10:05

Right. So it's not really in like standard of care yet, right? This is all still in research study form, like clinical trials.

SPEAKER_00 10:16

Well, yeah. So if you think about um dementia as having uh in particular Alzheimer's disease, because that's the best studied, you have a preclinical period where you see changes in biomarkers. Yeah. And then you see some subjective complaints sometimes of people saying my memory's not so good. Then you start seeing objective um uh mistakes that people make, you know, deficits, and they call that that is called mild cognitive impairment. And then they begin to have functional impairment as a result of this, which is true dementia. Uh and that that dementia progresses in multiple, multiple complications. Yeah. So, you know, it's basically it's a pathway from having biologic disease to having clinical disease.

SPEAKER_01 11:14

It always worries me, you know, like when we're testing, you know, some of these biomarkers or you know, doing some of these amyloid PET scans, you know, whether it's like if you have it, then it's like 100% that you're going to get disease. You know what I mean?

SPEAKER_00 11:32

Yeah, that's a good question because that would mean that the tests are perfect. Right. And the the tests aren't perfect. Uh there several of them are very good. Um and certainly the certain brain scans, such as the PET scan. If you have a PET scan the abnormalities, you you pretty much have Alzheimer's disease. There's just not much way around it. But people who have amyloid, which is the precursor to Tau, um, it takes a while from having amyloid positivity in your brain to actually having symptoms. And indeed, uh if you have positive amyloid in your brain and you have a negative PET scan, uh only uh 20% will convert over a six-year period. So in particular in geriatrics with older people, they may have competing morbidity and may not live to ever express their dementia.

SPEAKER_01 12:37

So I guess what would you tell patients now about um like would you recommend they get tested?

SPEAKER_00 12:46

You know, wait, I you know, I think now we're saying that like if there's red flags, right, then that might be a potential time to I I think the and I think in in the in the near future within the next few years, there's gonna be a lot more attention paid to assessing cognition in the office.

unknown 13:06

Yeah.

SPEAKER_00 13:07

Even by primary care docs. And say, geez, is this person cognitively normal? Um and in which case you just retest in another year or something like that. Or is this cut person cognitively abnormal? And if they're cognitively abnormal, in other words, they either have MCI, milocognitive impairment, or they have dementia. The next question is to them you know, there is a medicine available. Um, it's cumbersome, it's uh has some side effects, uh, it has to be administered through an infusion. If you were eligible for that, would you be interested? And that's what I will frequently do is I will ask them to get their level of interest because if they're not interested, then there's no point in pursuing things much further. If they are interested, then you know, next step would be a blood test.

SPEAKER_02 14:11

Okay.

SPEAKER_00 14:11

If if they have cognitive impairment. Right. And if that blood test is positive, then referral to neurology, which is where uh most of the infusions of these anti-amyloid drugs uh occur in neurology practices.

SPEAKER_01 14:28

So for the patients that aren't interested, what are the main reasons that they give you?

SPEAKER_00 14:34

Um I don't probe to why they're not interested.

SPEAKER_02 14:38

Ah, okay.

SPEAKER_00 14:41

You know, it's I try to explain as much as possible and they answer their questions. And then they don't really have to justify their decision.

SPEAKER_01 14:50

Right, right. Oh my gosh. So these primary care physicians have to start doing cognitive testing. What would you want them to know?

unknown 14:58

Trevor Burrus, Jr.

SPEAKER_00 14:59

So I think that this uh in fact I was working on a paper this morning addressing this directly, is that right now primary care is such a difficult field to be in. Yeah. There's so many pressures on on uh primary care providers. And one of the things we hate to do is add anything to their plate.

SPEAKER_01 15:25

One more thing, yeah.

SPEAKER_00 15:26

One more thing, you know, it's just enough to drive them out of practice. But um there aren't going to be enough neurologists or geriatricians or psychiatrists to do the initial assessment. Right. Uh so in many respects they're they'll have to step up to the plate, and that is being more comparable with a more comprehensive exam. This is not just like a mocha exam or a mini mental state examination. It's not a mini cog. Those are just get you into the door of knowing who you need to be tested further. This would be a full cognitive exam. So they would need to be comfortable with with doing that. Like a neuropsychic exam? Like, more like a neuropsychological exam? It's a cognitive exam.

SPEAKER_01 16:15

Yeah.

SPEAKER_00 16:16

Yeah. It's not formal neuropsychological testing, which is, you know, hours and you know, all these uh batteries of instruments. But this is, you know, spending 10 or 15 minutes with a patient and you know, asking questions that assess the the key domains of of cognition, uh, memory, personality, um, executive function, um visual spatial personality, you know, all these things. Right, right.

unknown 16:45

Yeah.

SPEAKER_00 16:46

Wow. And you know, be able to determine whether someone you uh is either cognitively unimpaired, with mild cognitive impairment, or or has dementia, uh, and then they would be referred if they're interested.

SPEAKER_02 17:05

Yeah.

SPEAKER_00 17:06

And sometimes that's too difficult.

SPEAKER_02 17:08

Yeah.

SPEAKER_00 17:08

Sometimes uh for I had a patient who was the president of uh Fortune 500 company, and this guy's IQ started out probably 165. Right. This guy was really bright.

SPEAKER_02 17:21

Yeah.

SPEAKER_00 17:22

But his family was noticing things, and anything I threw at him, he had no trouble with. Yeah. And he wouldn't do neuropsychological testing, so we wound up getting a um FDG uh PET scan. And sure enough, he had dementia. Uh, he had Alzheimer's disease, and three or four years later, he looked like every other end-stage dementia patient. Um but um so there are gonna be people who uh a primary care doc, even a geriatrician, is not gonna be able to say you have dementia, you don't have dementia. Right. And in those cases, uh I refer to for neural neuropsychological testing. And basically what I tell patients is the questions that I ask you, they're gonna do many, many more, two or three hours of testing. And the the reason I suggest it to them is it to point out the deficits and really help us with some diagnostic accuracy.

SPEAKER_03 18:22

Yeah.

SPEAKER_00 18:22

Whether how much of this uh is due to cognition, how much might be due to mood or affect. You know, depression can can affect performance on cognitive tests. Yeah. Uh what kind of pattern is it? Is it more of a pattern that's consistent with uh Alzheimer's disease or frontal temporal dementia?

SPEAKER_01 18:43

Yeah. I think I've told patients like it'll give us an idea of like your strengths and your weaknesses. That's exactly right.

SPEAKER_00 18:50

What what where your strengths are and what what you have to build, you know, surround yourself with to compensate to the Trevor Burrus, exactly.

SPEAKER_01 18:57

So how can we adapt, maybe, yeah, to some of your weaknesses. Right. I don't know. I it's been it's been tough. Like um, you know, we've been trying to get age-friendly implementation at the V at the VA, and so mentation, right, is one of the M's. Um but trying to do that in the primary care setting has been a challenge. Um, it's hard.

SPEAKER_00 19:21

I mean, it's it's hard. You you have a short uh visit when you're supposed to cram everything into it.

SPEAKER_01 19:28

Exactly.

SPEAKER_00 19:29

Sometimes what I'll do is I'll say, let me just bring you back and we'll focus only on a cognitive exam. You know, we we need to have an extra visit just for the cognition testing and metal status testing. Let's do it.

SPEAKER_01 19:42

Right.

SPEAKER_00 19:43

Uh otherwise it may never get done.

SPEAKER_01 19:45

Yeah. I guess the other thing is, is it possible for somebody else? You know, so maybe like um, you know, a nurse, you know, when they're doing the initial intake, you know, to maybe do a screening and to have a result of that.

SPEAKER_00 19:59

So uh that's a great um a great question because indeed uh with things like the annual wellness visit, in our clinic we'll have the um uh uh LVNs, the nurses, do a mini cock.

SPEAKER_01 20:15

Okay. Oh, yeah.

SPEAKER_00 20:16

That is just a screening test.

SPEAKER_01 20:18

Got it, got it.

SPEAKER_00 20:19

Now one of the things uh this is another Pandora's box that's opening up, is that there are a number of computer um testing uh of people who um you know are they pretty good. They're pretty good and they're being marketed uh already. I don't think they're reimbursed, uh, but they are being uh being used and um they they they have a lot of advantages.

SPEAKER_01 20:47

Aaron Powell Interesting. So could that be rolled out in clinic?

SPEAKER_00 20:51

So it's like, okay, sit here, you know, kind of not not in our specific clinic, but but nationwide it is, and internationally it is. Or they could do it at home.

SPEAKER_01 21:03

Right, right, right. And then bring the results to us, or like we get notified somehow, right? Yeah. Yeah.

SPEAKER_00 21:10

You know, basically it would be on your health systems platform, probably. And they would just log in.

SPEAKER_01 21:15

Yeah. Okay. I mean, so all these things to maybe help the primary care.

SPEAKER_00 21:20

Yeah. Yeah. But they're still it's not gonna totally eliminate it.

SPEAKER_01 21:25

Yeah.

unknown 21:25

Yeah.

SPEAKER_00 21:26

Because somebody's gonna have to talk with the patient.

SPEAKER_02 21:29

Right.

SPEAKER_00 21:30

And explain their results. Yeah. And talk with them about whether they would consider anti-amyloid therapy. Yeah. And talk with them about end-of-life care uh at some point. And so the the uh primary care docs, we can help them a lot, but but they're still gonna be the uh the point uh guard.

SPEAKER_01 21:52

They're gonna be the center of the gatekeeper. Oh my gosh, I know. Wow. So now the question is. How we can um, I don't know, like give primary care physicians the tools, right? To do this.

SPEAKER_00 22:09

Yeah, and it's not necessarily sitting in a classroom, although that's the first step.

SPEAKER_02 22:14

Yeah.

SPEAKER_00 22:15

The first step is making people aware. Yeah. But I I think so many times people understand what the instruments are and understand what it is, but they just haven't taken that step of integrating it into their practice. So it really is a matter of choreography. Yeah. When you think about your office visit or your day or your trajectory of care for that patient, when are you gonna fit this in?

SPEAKER_02 22:44

Yeah.

SPEAKER_01 22:45

Definitely.

SPEAKER_00 22:46

It's not just knowing what to do, it's have having a place for it.

SPEAKER_01 22:50

Right. So in the in like the workflow, right? How to integrate that into the workflow.

SPEAKER_02 22:57

Yeah.

SPEAKER_00 22:58

Wow.

SPEAKER_01 22:59

That's gonna be a lot though for them still.

SPEAKER_00 23:02

It is, yeah. It's a bit but the the problem is that um dementia's not going away.

SPEAKER_02 23:08

Yeah.

SPEAKER_00 23:10

And uh baby boomers like myself uh are getting older. Yeah. And the in 2036 they will begin to uh turn 90.

SPEAKER_02 23:25

Wow.

SPEAKER_00 23:26

And by the time you're 90 years of age, you have about a one in three chance of having dementia. So just think about those 70 million baby boomers who are still around. Right. And uh many of them will die, but you know, think about a third of the ones that are left having dementia. It's gonna be enormous numbers. Yeah. So it's gonna be a very large part of uh of a primary care physician's practice. Yeah, definitely.

SPEAKER_01 23:52

Didn't they say 2036, like that's when the number of older adults is gonna be greater than the number of children, I think?

SPEAKER_00 24:00

It may be before then. Yeah, it actually may be before then. Yeah, yeah.

SPEAKER_01 24:05

Okay, so then I guess I wonder where geriatricians fit into this, then.

SPEAKER_00 24:11

That's a good question. Um I I think geriatricians uh serve several roles. One is they will provide primary care for a lot of these patients.

SPEAKER_03 24:22

Yeah.

SPEAKER_00 24:22

Yeah. They're just it's just a good fit because they have multiple problems and and at uh identifying and trying to attain goals that cross diseases is in their wheelhouse. Uh they also may be consultants. They may be the people who primary care docs refer to to establish a diagnosis.

SPEAKER_03 24:47

Right.

SPEAKER_00 24:48

Um but that can't be either their sole role, and primary care can't solely refer to geriatricians because there aren't enough of us. And it's interesting because I was thinking about this earlier today, is that the three areas that three disciplines that really are most appropriate for dementia um neurology, geriatrics, and psychiatry, none of them are growing very fast. Certainly not to keep up with the demand that we anticipate.

SPEAKER_02 25:22

Yeah.

SPEAKER_01 25:26

So we need something to motivate young, like medical students, right?

SPEAKER_00 25:32

I don't know that that's going to happen. I I just don't know that that's gonna happen. We've we've been trying that for 30 years that I've been around here in pediatrics, and we haven't gotten much traction. Um, I think it's it's probably time to recognize that no matter what we throw at people, they would prefer to do other things that are more kind of task-oriented, more defined, uh, you know, things that um that don't aren't as complicated or as messy as what uh our patients typically um uh uh confront us with. Yeah. But you know, those of us who are geriatricians love it.

SPEAKER_01 26:18

Yeah, totally.

SPEAKER_00 26:19

The messier the better.

unknown 26:20

Yeah.

SPEAKER_01 26:22

Exactly. Solving a puzzle.

SPEAKER_00 26:25

Yes. Yeah. Well, and and being there for your patients wherever they are. For sure. Um I like to say that, you know, uh about half of my patients are I'm kind of the the closer. I'm the last you know, physician that will care for them. But the other half may get better. Yeah. And that's one of the wonderful things about geriatrics is trying to meet people where they want to be. Yeah. Whatever their real goals.

SPEAKER_01 26:52

Yeah. Anything unfinished about this conversation? Like anything else that, you know.

SPEAKER_00 27:00

You know, it's a great time for for dementia. It is a great time for dementia. Um two two big um currents. One current is the science is rapidly advancing. When I gave my grand rounds uh last August, between then and now, so much has changed. So it's an extremely exciting time. And it's not only for Alzheimer's disease, it's for diseases like Lewy body dementia. There are new drugs that are being tested in trials. There are very interesting diagnostic techniques for, for example, for Lewy body dementia doing skin biopsies to determine whether they have alpha-sinuclein.

SPEAKER_01 27:43

Yeah, that's cool.

SPEAKER_00 27:44

Uh, really interesting stuff.

SPEAKER_01 27:46

Yeah.

SPEAKER_00 27:47

Um and the second is that uh second big current is that there's a tremendous amount of interest in this. And the National All Science at World Project Act, which was uh started in 2012, um continues to gain traction. And things like the Guide Program, which is a new Medicare program, it's a demonstration, but they're planning to uh give comprehensive dementia care to 200,000 people with dementia to see if it works.

SPEAKER_01 28:23

Wait, date interest from whom?

SPEAKER_00 28:26

Federal government.

SPEAKER_01 28:28

Okay.

SPEAKER_00 28:28

Yeah. Okay. Interest in the federal government, interested um in in industry.

SPEAKER_02 28:34

Okay.

SPEAKER_00 28:35

Um interested in in uh pharmacological, pharmaceutical companies. You know, there's uh there's uh philanthropy. There's tremendous interest in in making it better because people realize what a devastating illness this is. And that nobody is immune.

SPEAKER_01 28:54

Right.

SPEAKER_00 28:55

Nobody is immune. If Ronald Reagan can develop it, then anybody can develop it.

SPEAKER_01 29:02

Yeah. Like the 40-year-olds and the 50-year-olds, right, about dementia, actually. We should.

SPEAKER_00 29:09

Yeah. Uh we should educate them but not test them.

SPEAKER_01 29:12

Right, right, right.

SPEAKER_00 29:13

That's the thing you don't want to do because the the tests are less uh accurate if the prevalence of the disease is very low.

SPEAKER_02 29:22

Okay.

SPEAKER_00 29:23

So what you'll see a lot in practice is somebody say, My mother had uh developed dementia, my aunt had dementia, and now I'm a sitting duck. Well, the the question you should ask is how old were they to develop their dementia?

SPEAKER_02 29:38

Okay.

SPEAKER_00 29:38

If they developed in their 50s or 60s, we need to act right now. They developed in their late 80s or 90s. Yeah. You know, until the results of these other trials that are using testing cognitive unimpaired people are completed, there's nothing we would do. And all you would do is worry.

SPEAKER_01 30:00

Okay. So that's going to be. So what would you tell them to do otherwise? So if they have this worry, but it's too early to test.

SPEAKER_00 30:11

Well, I would tell them to do basically the best preventive measures we know. And it turns out we we do have some evidence about preserving cognition, and it's lifestyle changes. Okay. Uh the lifestyle changes fall into four buckets. Uh one is physical activity and exercise. Number two is diet. Um, and that uh particularly Mediterranean type diets. Uh number three is um modifying cardiovascular risk factors.

SPEAKER_02 30:45

Okay.

SPEAKER_00 30:46

Because a lot of these uh dementias are are multifactorial, mixed dementias, and if you can reduce the cardiovascular risk, you reduce the overall risk.

SPEAKER_01 30:56

Okay. So it's like blood pressure or cholesterol.

SPEAKER_00 30:58

Blood pressure or cholesterol, yeah. And exercises there, too. Yeah, that's true. Um and then the last is cognitive training. And that's the one that is still um the softest, I think. Uh it's the softest because it didn't seem to be as effective in some of the early trials. In the more recent trial, uh the U.S. Pointer trial, the the adherence to cognitive training wasn't very good. Okay. Plus, there's a problem with something called transference. So they always say, you know, do crossword puzzles and you'll never get demented. Um but what doing crossword puzzles does is makes you a better crossword puzzle writer. It doesn't transfer to other things. So um, you know, the rack the exact uh prescription for cognitive training is still not known. Um but those those are the four. The um the uh exercise, the diet, um, the cardiovascular risk factors, and um cognitive training. Cool.

SPEAKER_01 32:03

So we're about five minutes to wrap. Okay. Sounds good. All right. Um do you consider like those New York Times puzzles some like similar to cognitive training? You know, so everybody's doing like the Wordle and have you heard of those?

SPEAKER_00 32:19

I don't know. I'm I'm not a puzzle guy. I just uh what can I say? I I I don't particularly enjoy puzzles. Um but uh what I do tell patients is be engaged. What is something that stimulates your intellectual curiosity? Right. And do that. Um there were some researchers out of Chicago, husband and wife team, where they're doing stuff with acting. They were training people to do acting, and there's a lot of memory and acting, and there's a lot of emotion and things like that, and they they were having some early success with it.

SPEAKER_02 32:54

Okay.

SPEAKER_00 32:55

So it's it's kind of what your choice is. Um asking me to do puzzles in the New York Times would be like torture. Um but on the other hand, I I can write a play. So uh That's true.

SPEAKER_01 33:09

Okay. Okay. And maybe socialization, I think we've heard more about socialization too.

SPEAKER_00 33:17

Aaron Powell Well, yeah, that's also something that's it's it's really individual specific. You know, some people just aren't very social people. And making them be cheerleaders at the age of 75 is maybe not going to be the most beneficial for them. They might find that actually very uh frustrating and uh not like it.

SPEAKER_01 33:38

Torture for them. Yeah. Okay. Dr. Rubin, thank you so much. Well, my pleasure. Thanks, guys. Pleasure talking.