Let’s Talk Memory Care Podcast

Speaker 0 00:00:05 My name is . I'm a regional director with Silverado, the world leader in providing care for those, with memory impairing diseases. Now whether it's through our innovative clinical models of care for our residents, our world acclaimed evidence-based nexus program for early stage dementia that combined science and social engagement, or the many partnerships with global leaders in medical and scientific research Silverado is not only committed to change in the lives of those with memory impairment, but through education. And by example, eradicating the stigmas that surround all dementias. We are currently changing lives in 20 communities across six States, and will soon impact even more lives as we open our new communities in thousand Oaks, California, and Bellevue Washington, which are both due to open in the next two months. And so speaking of Bellevue Washington, our esteem speaker today is based just across Lake Washington in the beautiful city of Seattle. Speaker 0 00:00:58 Uh, Dr. Christopher roads is a clinical neuropsychologist specializing in the evaluation and treatment of dementia and neurodegenerative disorders. He is a member of the board of directors of the Washington chapter of the Alzheimer's association, and he chairs the health medical care subcommittee for the dementia action, collaborative implementing the Washington state plan to address Alzheimer's disease and other dementias. He currently serves as a neuropsychologist for the university of Washington memory and brain wellness center at Harbor view. And he's an associate professor in the department of neurology at the university of Washington school of medicine. So Dr. Rhodes, thank you so much for joining us today and I'm going to hand off to you. Yeah, Speaker 1 00:01:37 It is an absolute honor and a pleasure to, um, partner with you today and Silverado in general, to talk a little bit about some updates in the prevention and treatment of Alzheimer's disease and related dementias. And I really appreciated your comment around decreasing stigma as that as part and parcel of the work that we do here at the university of Washington memory and brain wellness center, including our clinic, uh, but also, uh, one of the longer running Alzheimer's disease research centers, uh, which is, uh, in its 37th year of continuous funding. I did today. I want to give you a little bit of overview, um, some updates around what we know about Alzheimer's disease and other dementias, and really focusing more on treatment. And my favorite part of my job is that I don't prescribe medications. I get to do all the non-pharmacological and, um, behavioral and lifestyle interventions and more of a cognitive rehabilitation approach. Speaker 1 00:02:37 Um, and a big piece of that are the programs and services that we offer here and that I've seen popping up from around the country. Very, very briefly. I don't want to bludgeon you with a lot of statistics, but I do want to draw your attention to the fact that dementia and Alzheimer's disease are worldwide problems. This is not constrained in the United States or Western. Uh, we know that there are somewhere North of 50 million people living with dementia, uh, currently, uh, that is kind of a tip of the iceberg. When you think about prodromal phases of mild cognitive impairment, or even pre mild cognitive impairment, where someone may have the beginnings of neurodegeneration that haven't manifested clinically. Uh, so we're, we're talking, you know, huge segment of the population and a number that continues to rise. So we know about 10 million new cases of dementia, uh, per year. Speaker 1 00:03:30 So roughly equates to about one case every 3.2 seconds. Um, and when we think about where this is occurring, the most, these are in low and middle income countries who occupy about 58% of the dimensional landscape or proportions, which will increase them almost 70% by 2050. And there are a variety of healthcare, uh, as well as contextual factors that drive that, uh, some of which intersect with genetics and predisposition, but really it's, as we will see in a bit here, the contextual factors in which someone lives is a huge predictor and dictator of who will go on to develop cognitive impairment and dementia, which opens the door for some thoughts about prevention and intervention of one of the statistics that is continuously staggering to me are the number of people who are undiagnosed. And these aren't necessarily folks in the mild stages who have some short-term memory difficulties, or maybe some word finding problems. Speaker 1 00:04:33 These are individuals who have functional impairment because of acquired cognitive changes. So we know here in the United States, only 45% of people with dementia have a diagnosis in their medical record, which when you think about that, what other healthcare condition would fall into that category? Could you imagine that 45% of people with cancer had a diagnosis in their medical record it again, multiple reasons for this, but it makes care so much more complicated. Uh, everything from a covering physician who doesn't know cognitive impairment is part of the mix that is a mediating variable for how people do other diseases to unplanned or even planned hospitalizations or surgeries, Speaker 2 00:05:17 A lot of Speaker 1 00:05:19 Impact in terms of how people recover from those things, how they fare in the hospital, rapid readmissions, many of the metrics that we're worried about in healthcare, and many of the metrics that people are worried about just in terms of quality of life. So we know that about 10% of people in India have a diagnosis. So this is a, this is a big issue, and we are working on changing that as are many other groups around the country and around the world. But you got a lot of work to do more locally here in the United States, about 5.8 million Americans with Alzheimer's disease, maybe 5.2 million of those folks are over the age of 65. Uh, we certainly see individuals who are in their thirties or forties with Alzheimer's disease and Alzheimer's dementia. Uh, we know that age remains the greatest risk, such that after 65, there's about a 10% general population risk, but that starts off very low at around 3% in the age band between your mid sixties to mid seventies, escalating up to about almost maybe a third, maybe even 40%, by the time you hit 85. And again, there's, there's a big distinguishing factor here in terms of having disease of Alzheimer's disease, the, the plaques and the tangles that constitute that versus the clinical symptoms and the functional interference that characterize dementia. So you could have the disease and have no symptoms. You can have the disease, have mild symptoms, or have the disease and have dementia. Come back to that. That's an important concept. Speaker 1 00:06:52 We also know that these large numbers of Securus and very, very important differences in terms of disparities for underserved and historically marginalized populations. So our African-American counterparts are about two, maybe 2.3, 2.5 times as likely to have Alzheimer's disease than a Caucasian counterparts. Uh, we know that, uh, Latin X populations tend to have, uh, both higher prevalence as well as be diagnosed later. And with more, it'd be your symptoms and that the vast majority about 66% of individuals with dementia are women. Uh, and some of that is related to age and differences in life expectancy. Some of that may be related to hormones or other, uh, either bio-psycho-social factors to drill down a little bit more specifically, and to provide a snapshot of what is occurring on the state level here in Washington state. Uh, we have about 120,000 cases, um, about 7 million people in our state. Speaker 1 00:07:57 And that's, uh, an increase from 2010 ish, but it really hasn't changed in the last couple of years. We are still expecting a significant increase of around 150,000 by 2025. I here in Washington, as in any many other places, it remains one of the highest leading causes of death. Uh, we historically had the third highest rate in the U S uh, behind North Dakota and South Dakota. We are now at six and some of that is, um, state by state, um, better job, public health accounting, and calling Alzheimer's disease as it caused them death or the primary cause of death, what it is versus attributing it to pneumonia, or some other condition that to cold because of Alzheimer's disease. And then these numbers are the ones that tend to yeah. Made the most, uh, particularly as somebody who works with individuals, with memory loss and their families are the unpaid who provides care. Speaker 1 00:08:57 So here in Washington, uh, it's an unpaid of a, uh, economy on scale of a major corporation, right? So $5.3 billion worth of care. If you were to pay those individuals for the work that they do to the tune of 250 million in additional healthcare costs for those caregivers. And for any of you who are frontline family professional or combination caregivers, I don't have to tell you the physical, emotional, psychological toll this takes. And often the caregivers health care takes a back seat to the individual with cognitive impairment or dementia. So as we came up with our own state plan for power, are we going to address this kind of silver tsunami and impending crisis that could be new as Alzheimer's disease? Uh, we asked the question of our legislature of 10% of this unpaid workforce can no longer provide the services that they're providing. Do we have the support systems and structures to step in to fill those gaps? And the answer was a resounding no, no way. We can't help the people who we know of currently with the things that we have, we need to be doing better. Speaker 3 00:10:08 Um, Speaker 4 00:10:11 And all of Speaker 1 00:10:13 These statistics that we just kind of ran through our pause to rethink Alzheimer's disease. And we know that the changes that come with aging are many, and some of that is visible and obvious, you know, wrinkles, or maybe you lose some height due to decreased height of your spinal column. But other things like changes in cognition are a little harder to assess. And it's one of the most frequent questions of what's normal, and what's not as we get older, um, we know short-term memory changes and after decades of research, we have a good sense of how much at what ages and what parts of short-term memory change, which is a little bit out of the scope of today's talk. But this idea that well Alzheimer's disease is just an inevitable consequence of getting older. Absolutely not. And we've got a much better understanding for aging that is successful and healthy. Speaker 1 00:11:07 And what does that mean and how do people get there and how can we do more of that as well as treating illness when it arises. And it really has made us rethink the stigma around Alzheimer's disease, which I really would imagine is a big driver of why only 45% of people are diagnosed. It's hard for people to talk about it. It's hard for primary and other specialty care providers to talk about necess. Um, so it's, it's, it's in the shadows still a bit. So I, again, I'm extra appreciative of your attendance here today, as you Speaker 3 00:11:37 Learn more Speaker 1 00:11:39 Trying to combat that stigma in your own communities. And one of the things that I will emphasize here is that one of our unique focuses or areas of focus is resilience and these ideas of retain strengths that not everything in Alzheimer's disease. So how can we capitalize on those retain strengths to promote function? Um, so if we think about kind of what's normal, what's not, we have this, uh, kind of graph of cognitive function and then over time. So these are decades or years in this green line represents the normal age associated changes, typically in things like how quickly we can process information, uh, short-term memory, not long-term or procedural memory or memory for facts, or how to do things tends to remain quite intact. Uh, some of which, even in the early to mid stages of Alzheimer's disease, you can capitalize on that. So around 65, there are these kind of Cardinal sets of changes that occur. Speaker 1 00:12:34 And there are some progressive changes after 85, not to the degree that impacts function may take longer to do what you need to do. We may have to work harder. It may be that you have to go back out into the kitchen to remember what you were going to go into the living room to get. Uh, but typically you can do what you need to do contrast that with this other process, something like Alzheimer's disease, where there's this gradual set of changes that occur at the microscopic level, in the brain, things that wouldn't be visible to the naked eye, even on autopsy. Um, and these are the plaques and the tangles that you've likely heard about with Alzheimer's disease and the character electrical characteristic, um, components of neurodegeneration, and these gradually increase over time, such that by the time they hit a certain level and start to affect the structure of the brain. Speaker 1 00:13:29 So the neurons and even larger regions, there are changes in cognition. So these plaques and tangles are pathological to the brain causes degeneration of brain networks and regions that gives rise to changes in cognition, which are kind of the symptoms of that. So again, you could have this disease process way over here on the left, where it's going on, but you don't have any symptoms whatsoever. You could be in the territory of mild cognitive impairment, which is a measurable difference between normal aging and how we're doing on things like tests of memory or language or executive functioning, or if those plaques and tangles and other pathological burden increases in cognition decreases such that it interferes with your ability to pay your bills or manager, medications, transportation live independently. That's where we crossed the line into dementia. So dementia is not a disease per se. It's a term that describes functional impairments that are caused by changes in cognition. Speaker 1 00:14:35 And when we think about all the things that can cause dementia, there are many, there are hundreds, all timers disease is one of if not the most frequent, but it's not the only one. So again, it's kind of an umbrella term and not as part of today's talk, but certainly excellent information out there around the differences between types of dementia. Um, I've got this here as a resource, and I'd be happy to provide these slides to, um, gracious hosts if they want to disseminate them. Uh, but this kind of breaks down the rough prevalence. So you can see about two thirds to maybe three quarters of all dementias are either due to Alzheimer's disease or have a significant component of Alzheimer's disease. And we can kind of work through the things that change in which parts of the brain are associated. Uh, the characteristic of Alzheimer's disease typically is something that starts very slowly and creeps on over time. There are no focal or dateable events like a stroke or brain injury, and there is a progressive decline versus something like Lewy body dementia, where there are significant fluctuations. Some days people are kind of at their baseline and other days more prominently confused. Then days you can see some of the other changes that distinguish these things. So this really, again, more for rent, Speaker 1 00:15:51 Because also important to talk about is this question of if I have Alzheimer's disease, and if I'm starting to show symptoms, how long do I have that is a common, common, common, common question of, is it going to be a year before I have more prominent problems or functional problems? And that's a hard question to answer, and we can prognosticate to a degree given what we know about the different stages of Alzheimer's disease, you can be pre-symptomatic for anywhere between five to 20 years, you could be in the MCI phase for a year to a decade. And then once you're diagnosed with dementia, you can live for two years to 20 years. So when you put all these together, this is potentially a 50 year disease. And some of the things that dictate how long people stay in these different stages are other health conditions, your age at which your diagnosis and the severity at which you're diagnosed, what you do about it, uh, how you respond to the medications that are available. Speaker 1 00:16:54 So there's a variety of different deterministic factors that will shape length within these different fans here. But I guess what I would want to impart is that it is not a death sentence. It is not a you've got Alzheimer's disease. There's nothing you can do. Here's your aerosept good luck to you. That that is absolutely not the story. Um, and unfortunately it's, it's been the story for a while. So, um, my hope today is also convinced you that this is, this is not something that can't be worked with, which gets us into the idea of treatment. So if we go back to the slide of gradual accumulations in neuropathology at the bottom and read, and this kind of change in cognition and yellow, right now, there is no vaccine for Alzheimer's disease. There is no disease modifying treatment that cures it or restore his memory back to baseline levels, but there are things that we can do. Speaker 1 00:17:53 And there are medications under investigation that seem to suppress that accumulation of pathology. So instead of this kind of sharp curve, it's still happening, but it's not happening at the same rate. And what that effectively does is keeps people in the milder stages and the state of the art right now are these multimodal interventions. That, again, it doesn't cure Alzheimer's disease. It doesn't fully prevent it, but if you can prevent late stage disease or mid-stage disease, where the greatest functional losses, or need to transition to a different level of care, uh, or more neuropsychiatric symptoms, whatever it may be, if you can prevent that, that's a huge advance. So how do we do that? And I'm going to just gonna put it up here. Um, this is, we surveyed literature around what's available in the treatment of Alzheimer's disease prevention and treatment. This is kind of the full package. Speaker 1 00:18:53 So paramount would be treatment of all the modifiable risk factors beginning as early as possible, ideally in midlife, but it's never too late. So if you're someone in your seventies or eighties, I would also disabuse you of any myths that, well, it's too late for me. The horse is already out of the barn. Of course, we go back in the barn. So we want to make sure that we're treating all the things that we know about for cardiac and heart health. And, um, you think about the brain and what goes from the heart kind of goes dumbly for the brain. Uh, we want to get people moving. So it's, um, sitting disease that we have, um, uh, getting people, moving, physically, getting people, moving mentally, keeping them engaged, avoiding cognitive retirement, uh, treating sleep disorders. We have a greater appreciation over the last four or five years for the importance of not necessarily quantity of sleep, but quality of sleep. Speaker 1 00:19:48 And what happens as we get into deep stage restorative sleep and three REM uh, phase sleep, what that means for how the brain kind of repairs itself or clears out amyloid beta, uh, what it means if you have Alzheimer's disease and in terms of speeding up accumulation of amyloid beta. So stay tuned for that. We're learning more and more. Um, and then other lifestyle things that we know were not good for brain health, like intervening with an excessive alcohol intake, um, a thorough review of medications, uh, both prescription and over the counter medications, we see a surprising number of people who are taking things like Benadryl or, uh, other sleep agents to help with sleep, but they have side effects that are certainly not good for your memory. Um, so a thorough review of medication drawn over the counter supplements and then medication options, things that are FDA approved for Alzheimer's disease and cognitive disorders, cardiovascular exercise, cognitive activation, cognitive rehabilitation, dietary interventions, managing stress well, um, meditation MBSR, or mindfulness-based stress reduction, being one method for that. Speaker 1 00:20:57 Um, and then perhaps most importantly, that can help serve some of these other things are keeping people with memory loss and you mentioned engaged in their communities. And I want to spend a fair amount of time talking about that. So let's go through each of these areas of somewhat briefly, but I'll give you some resources that you can take a look, a deeper look if you're interested. So in 2017, the Lancet commission pulled together an international group of experts, researchers, clinicians, and took a survey of what do we know about Alzheimer's disease from prevention to end of life care. And at that point, uh, they determined that about 35% of all dementia is, are preventable. Um, and with the revision that just happened last year, that number, unfortunately, it's gone up to 40%. So if we kind of go through the different areas, it's the lifestyle or lifespan intervention. Speaker 1 00:21:52 Also, if we could improve early childhood education, that would eliminate 7% of all dementias. Part of that is building cognitive and cortical reserve. Part of that is increasing healthcare literacy and providing better socioeconomic opportunities in mid-life. If we could address hearing loss or prevent hearing loss that would get rid of 8% of all dementias and a complex relationship between the hearing loss and the brain, what happens on the, in the cortex as we experienced sensory change, uh, traumatic brain injury, uh, doing a better job of protecting the head in car accidents or sports, um, hypertension, alcohol, obesity, uh, late life, uh, smoking, uh, social isolation, depression, all of these things. If you put all these together, you can eliminate 40% of all dementias and that as we're going to see in a minute here, potentially offsets the risk of things like genetics, which we can't modify. Speaker 1 00:22:57 So there's definitely a role for prevention, and it's been fascinating to see our departments of public health, the CDC, other organizations take a strong interest in what can we do around dementia prevention. As we also focus on providing treatment for people who need it, and that treatment takes multiple forms. So here's some data on one of the FDA classes or approved classes of medication for Alzheimer's disease. And if you're not used to looking at these graphs or plots, um, the way this works is, um, this line here with the zero would be, there's no difference between a placebo or a sugar pill and the medication, anything that is over on this side is a positive treatment effect. Anything over here would say, actually the treatment makes things worse. And as you can see, there's a small treatment effect across all these studies that kind of averages out to right here, which is not a profound, restorative, huge disease modifying intervention, but as we know clinically, and from other studies, things like aerosept or other medications, um, help with symptoms and may stabilize things for a period of time, uh, for some individuals there's a pretty wide response. Speaker 1 00:24:14 So there's a role for these, uh, similarly the other class of medication, the NMTA receptor antagonists also, uh, have a pretty decent, uh, treatment effect, uh, smaller studies, fewer studies, it's a newer class of medications. So it's not the kind of treatment effect, like, you know, insulin for diabetes, the score, you know, Staten for cholesterol, but it's not kind of what you sometimes hear, which is they don't do anything. There's no point in trying them, the data would argue otherwise. And I put these here not to endorse any medications, but just give you a survey. What do we know about the FDA approved medications that are out there? And then how does that stack up with the other things that we could do? So now, if we look at that same kind of a meta analysis on cardiovascular exercise, you see the same thing that the treatment effect is overall. Speaker 1 00:25:05 There's something there, and this is in people with full blown dementia. So the data also suggests, and there might even be a greater treatment effect in MCI or early the earlier we do these things, the more window of opportunity we have to intervene. So again, it's not a, you know, if you're already into mid related stage, you mentioned there's nothing to do. Just the, the window is closed quite a bit. So the earlier we do these things the better, um, I suspect that at least some of you have a question about what should I be doing. And most of these things are in D cardiovascular exercise. So things that get your heart rate up in your cardiovascular training zone, um, you always, always, always would clear this with your primary care provider or cardiologist or other, um, person, healthcare provider, who knows you well. Uh, but the, the data is pretty impressive and the things you could do, uh, and I'm, I'm kind of, sorry, the answer is exercise, but the things that you could do that have an impact on your project and functioning your dementia risk cardio is, is it, uh, the studies would suggest that, uh, we're somewhere in the territory of 20 to 30 minutes, you know, five times a week in that zone. Speaker 1 00:26:20 Uh, there was another lovely study that was done that looked at 45 minutes, four times a week, a little more intense rate, but still in 60 to 80%. Um, and the, the effect is about the same. So again, that importance of physical activity. And when you think about what that does around blood flow and sending almost double the amount of fuel to the brain, what that means in terms of production of the neuro-transmitters that the brain uses to communicate stimulation of connections between the neurons that are still healthy and working, there are four or five mechanisms by which this is a plausible intervention. When we look at the same kind of idea, but with cognitive activity. So keeping your brain exercised there is, uh, also a modest effect. So these are things like, um, you know, crossword puzzles, drink, saws, all the, all the things you hear you're supposed to do. Speaker 1 00:27:15 There's some benefit to keeping your brain active when we get into more detailed, actual cognitive training. So these would be the computerized or paper and pencil programs that are designed to really push your brain, um, more than just activating it, but actually training up specific types of cognitive functions, uh, in mild cognitive impairment, you can see that there is a more significant effect than there is in Frank dementia, uh, which again, stands to reason that in an earlier stage, there's a wider window for intervention. And I, I would disentangle that from cognitive rehabilitation. So these would be things like, um, activities that are designed or delivered in a medical context by either a speech and language pathologist or a cognitive rehabilitation specialist in neuro-psychologist, uh, that focus on either strengthening or capitalizing on neuroplasticity, uh, versus coming up with things that help us compensate. So many set is a great example of that over here on the right, where if I have memory problems that interfere with my ability to track my medications. Speaker 1 00:28:26 So the things internally that I would normally rely on aren't working the same. If I put some things into practice externally, like a mediset coupled with some large firms and reminders, and maybe even a tracking sheet where I can write down the time that I took it, that's a great example of a compensatory strategy. Um, and likewise, when we think about memory short-term memory, um, there are four basic components to the short-term memory. You have to pay attention, you gotta get it in, you gotta keep it there and you got to pull it back out when you need it. So encoding getting it in storage, keeping it there, retrieval, pulling it back out when you need it. And there are different interventions, depending on which part of that process is breaking down or experiencing, um, more problems. And that's the benefit of the detailed memory testing that we do is we can disentangle those things. Speaker 1 00:29:15 Uh, people are also curious about what should I be doing diet wise? And the mind diet is the best study. At this point. It's a derivation of the Mediterranean diet. It comes from our colleagues at rush university, and this was a lovely study. That's goes back about six years now, five years, uh, looking at about a thousand people each 58 to 98 and followed them for four and a half years. And they were randomized to diet as usual versus the mind diet, which is the dash diet, the antihypertensive or high blood pressure diet, coupled with the Mediterranean diet. Um, they got to have one glass of wine, which I think they threw in there to make sure people did it. Uh, and what they found was that for the people who stuck to the mind diet pretty rigorously over that four and a half years, there was a 53% reduction and who developed Alzheimer's dementia. Speaker 1 00:30:10 They didn't check to see if you had the disease, but not the clinical symptoms. So you could possible, but certainly didn't have the outward memory problems or functional problems for those who stuck to the diet modestly, it was about a 35% reduction. So again, it's not an all or nothing. And when you think about diets, if any of you have tried to change your diet, wholesale is incredibly hard to do. And one of the things that I like about this is they provide practical suggestions around modifications that get you closer. So worth investigating. Uh, my understanding is that they are doing a trial now as more of an intervention for people who have, uh, diagnosed and obvious memory changes to see, does it change progression? So stay tuned. I haven't seen any updated data yet. Speaker 1 00:31:01 So we also, there are similar data. If we look at Michael and space, stress reduction programs in terms of coping with cognitive changes, uh, but all of these things really speak to the importance of the choices that we make. The things that we can do that are within our sphere of influence. And that's in my experience and my bias as a neuro-psychologist, that's where people are most interested in, what, what can I do? And sometimes there is this, I've got the diagnosis after months, or even years sometimes, and going through different procedures, I've got a diagnosis now, and these things are the now watch, right? How do we get you moving? How do we get you eating better, sleeping, better dealing with stress, better staying engaged in your community. And some data that was presented at the international conference for the Alzheimer's association back in 2019, uh, was that the more of these things we do, the more benefit they seem to have. Speaker 1 00:31:59 So these are the, the five, uh, kind of common factors here, healthy diet, physical activity, like to moderate alcohol intake. So a, a serving, uh, which you need to get specific about that. A fifth of gin is not a serving. Um, I learned that when I worked at the VA and smoking no amount of smoking and safe and then cognitive stimulation. So if you do four or five of these statements and are pretty committed to them, don't have to be perfect. Uh, that confers about a 60% lower risk of Alzheimer's dementia. If you do two or three, that might be a 40% lower risk and our risk for things like a Bowie four or other known genetic risk factors that aren't fully penetrated, deterministic genes tend to be more early onset. Um, this may be significantly more than that. So we are not just our genes. Speaker 1 00:32:51 I would say that I would also say these things are not easy to do. They sound simple, right? But it takes commitment. It takes discipline, it takes support and some partnership with your providers to do these things. Accountability is a wonderful thing in the name of time. I'm not going to spend too much time on this, but I did. I did want to tell you for those of you who aren't in Washington, um, that your state has a similar infrastructure, but depending on where you are, it may be at a very different place. So each we have a national plan for how we're going to address Alzheimer's disease. And there's two main pieces to this. One is prevention effectively treat Alzheimer's disease by 2025. And we are talking on that deadline, um, closer and closer. And also if you look over here in 2011, federal funding for Alzheimer's disease was pretty abysmal and due to a variety of efforts, including Alzheimer's impact movement, research dollars and alternatives disease have logarithmically increased almost, which is wonderful because it attracts brilliant young scientists, uh, who see a viable career path and typically have a personal connection to the disease. Speaker 1 00:34:04 It's been great to see this be so well supported by NIH. And, um, we are the first time in the 20 years that I've been doing this, I feel pretty confident that we're on the cusp of something very significant in terms of treatment. So each state has to have its own exponent of that and local delivery. And, but true here in Washington, true. And all the other States I've been to States are heterogeneous placements. So Eastern Washington is very different than Western Washington. The Seattle area is very different than South West Washington. So it's lots of needs, lots of different regions, resources, geography dictates some things. And this has been a long process, but what started in 2017 13, excuse me, uh, led to our first products in 2017 and our estate plan, uh, which was a governor appointed work group that created this plan transitioned into an implementation group. Speaker 1 00:35:03 And this is where I think we've been successful is this, uh, large interdisciplinary group, including people with Alzheimer's disease and care partners, as well as legislators and people from the clinical and research world myself. Um, and we were tasked with, what can you do with no money that has high impact? Uh, and we did. Um, so we created a dementia roadmap for people living with Alzheimer's disease and other dementias. Uh, we've received over a million dollars in state funding with set of masks that is before the legislature right now, tough time to ask for money, but we've got a proven record of doing things without it. I'll give you an example. So the roadmap is a really fantastic resource, uh, and that number of 75,000 I think is a conservative estimate. Um, but it, it takes you all the way through wondering and worried all the way to I've got late stage dementia. Speaker 1 00:35:59 What are the things that we should be thinking about? What are the resources that can help? Uh, it is to a degree Washington state specific, but the analogs of the different programs and services and organizations are out there. And as a matter of fact, for a lot of our tools, we relied heavily on things that came out of Minnesota. Um, so you extended expanded early stage programs. We've got some webinars on, if you're interested in starting an Alzheimer's cafe, how would you do that? Um, here's a six page list just updated a couple of weeks ago of virtual resources for caregivers. Um, so lots, lots and lots on there. Uh, and the last thing I wanted to talk about, uh, that we have embarked on as of June is a virtual education virtual clinic, or primary and allied healthcare providers in rural and under-resourced parts of the state, uh, where we have an expert hub here at the university of Washington consisting of an interdisciplinary team. Speaker 1 00:37:02 And then we've got spoke sites providers out in the community. We meet twice a month, we do a very brief kind of a lecture kind of educational piece. And then we do cases and that's, it's an all teach, all learn, case-based learning model. Um, and so far we've provided almost 250 hours of instruction. Uh, you can see our sites here. Uh, we've got plans to expand, uh, down the West coast. Uh, stay tuned. It's a little early to talk about that. Uh, but it has been amazing. We've got 22 sites, 53 providers that are participating and what each one of these stars becomes is a local resource for dementia care. So we've got people now across the state who are the go-to for, if I have this kind of an issue with a patient or in my system of how do I do this? These are our, these are our local champions. Speaker 1 00:37:55 And in the name of leaving about 10 minutes or so, for questions, I wanted you to, um, kind of be left with this, which is really our ultimate mission, which is how do we help people and partner with people, living with memory loss and their families to have as good a life as possible. And, uh, as somebody with a personal connection to the disease, I wouldn't sugar coat it and say, it's, you know, boy, what a, what a great challenge to, you know, add to your later years. This is hard. This is one of the hardest things to deal with, uh, for spouses, for family members and the idea that there are some positive aspects and the idea that there are things that we can do to help and maximize those. That's the approach that we want to take. So to preserve function, to keep people engaged. Speaker 1 00:38:46 And, you know, if you can't fight this, you might as well dance with it and try to leave as much as possible. It's the resources, which again, I'll, um, these are some national, some local, I will thank you for your attendance. Uh, I'm going to leave my contact information up here. Um, I also liked this picture, uh, because, you know, lest you think I'm in the ivory tower of a university of Washington. I am in the brick tower of Harbor view, which is our regional level one trauma center, uh, and really still identify as a clinician primarily, Speaker 0 00:39:21 First of all, Dr. Rhodes, thank you so much wonderful presentation so much to take away. And thank you also for offering to share the slides. I know a number of folks have asked and we'll be happy to distribute those. So thank you for that. You know, we do have a number of questions and we'll try to get through as many as we can. One question came up and I got to tell you, you know, hearing you talk about the programs, the approach that you're taking. And I mentioned, uh, you know, our nexus program or early on, you know, we, we, we base it on pillars like cognitive exercise, physical exercise, stress reduction, uh, purposeful social activities, support groups, right? Uh, you know, what, what we have seen is that, you know, academic research has, has validated the participants in our nexus program. They show a statistically significant 60% improvement in cognition when compared to those without such treatment. And we're seeing what you're seeing. So the question is, and I love your term diag diagnose and audio. So I'm going to steal that by the way Speaker 1 00:40:17 From somebody too. Speaker 0 00:40:19 So the question is given that we see these benefits, you know, given that so many of the experiences that we hear often as somebody's diagnosis, maybe you get some Sarah aerosept or Seroquel as you referred to earlier, and then it's adios. So how do we train the greater medical community, those on the front lines to pay a little bit more attention and to really deliver this message that we are seeing through our nexus program, through what you're seeing, how do we get the message across so that people have a better experience of at that initial diagnosis? Speaker 1 00:40:50 Well, that's the $64,000 question. And our approach is that it has to happen at all levels. And we have been pretty intentional around working on changing training at the graduate level, graduate medical level, but you also need to reach the providers that are out there in practice that didn't get a lot of training. So one of the first things that we did for our state plan was to do a survey of primary care providers. And we had about 250, 275, I think, respond, which is a pretty decent number. Um, and 79% said, this is absolutely important. I have no idea what to do. Didn't get any training, don't know how to bring it up, talk about it. When, what tools to use, don't know what treatments exist. So the training needs are, and my take on it is that primary care specifically want to do the right thing. Speaker 1 00:41:39 They just don't have time to do so. It has to, you know, they have to be educational programs. There has to be incentive. So it's been really interesting to see these new billing codes come through that will reimburse providers at high levels for doing the work, the challenges, you know, unless you also give them note templates and way to interface with their electronic medical record, or, you know, and I don't know that mandated education is the way to go. Although the Massachusetts model is very interesting where providers need a certain amount of CME around dementia care in order to renew their license. Um, so you got to have a provider base, that's incentivized to do it. We were presuming they want to do it. Uh, but then you also need to have a public and, um, population that knows what to ask for, like, you know, Hey, my Medicare annual wellness visits coming up, this is a great time to maybe check out my cognition, right? And then you need programs and services for providers who can't do it all to be able to refer people to. So it's gotta be this kind of three part piece or otherwise they all kind of, they don't gain much traction. Speaker 0 00:42:45 Got it. Okay. Thank you. A question that we have here. Also, you talked earlier about the benefits of sleep or quality of sleep. And so a question that we have here is what is the safest sleep aid for the brain? If you have trouble staying asleep. Speaker 1 00:43:00 Yeah. Cognitive behavioral therapy for sleep. I mean, any kind of behavioral interventions that the order in which we proceed here and sleep is such an incredibly common thing. I would say of the people who come to our clinic who have cognitive problems that look an awful lot like Alzheimer's disease or something like that, that don't end up having Alzheimer's disease undiagnosed, untreated sleep apnea is in the top three. So that's one of them. So the first line of intervention would be just the basic sleep hygiene things, which, again, it sounds simple, but we don't always do so limiting screens for 45 minutes before you go to bed, making sure the bedroom is, you know, it's for sleep and sex only. It's not, you know, you're not doing work in there. You're not watching TV in there. Um, before caffeine exercise, there's a whole, like basically nicely outlined series of things we can do. So that's number one. Uh, the next level of intervention, if that's not quite working, uh, would be something like melatonin. And then you can start to get into some other things, like some of the other medications, like Trazadone, and then you can escalate from there. But I'd say the behavioral things first melatonin second, and always, I mean, obviously always talk with your provider about anything you're thinking about trying, or if you're stuck, if you're like, I've tried these things, I've done as much as I can of camp, if it's not working. Speaker 0 00:44:18 Understood. Okay. Uh, Mark has a question. He says, your presentation is excellent. I'm doing the things that you described as difficult specifically in terms of exercise and diet. I'm thankful that you did not go into all the meds. My question is, do I help myself by taking a daily pill, something like a vitamin or any of the OTC memory meds now in preparation for the future. Speaker 1 00:44:40 That is a great question. So the literature that's out there right now, everything is kind of comp as a wash and things have been investigated like vitamin B12 of Gingko biloba. I mean, there's, it feels like every year or so coconut oil. I mean, there's always something right. And the best data that I have seen, and my I'm channeling, my providers that I work with here would say, unless you have a deficit in something, these extra levels of things likely not helpful, there may be individuals who are really responsive to that, but until we know who they are by and large, there's no data that would support that unless you have a deficit. Okay. All right. Shannon is a boy supplement. Companies would love to separate you from their money. Speaker 0 00:45:33 That's very true. Shannon wants to know. She says, I'm curious if there's been any correlation found between a history of mental illness and dementia. Additionally, as lifestyle factors are so impactful, have there been studies that link sleep apnea with dementia? Speaker 1 00:45:48 Yeah. So yes. And yes. Um, so it's, it's a complicated relationship. So there is data that would suggest long histories of major depressive disorder, PTSD, uh, especially if not treated raise risk for later life dementia. Uh, and there's a complex interplay of kind of what happens from a neurochemical and biological standpoint that probably opens the door for that. And there are some arguments around, you know, does it cause it, or does it maybe open the door as sooner? So if you're somebody who would develop Alzheimer's disease at 75 and you have a lifelong history of untreated depression, is it now 65 that you're experiencing that that's a little murky. Um, but yes, there is an association between those things, uh, and later life dementia, um, not necessarily for episodic kind of situational things. I mean, we all have things that go South and have a hard time with that. Speaker 1 00:46:45 That's a very human kind of thing. Um, and not necessarily for depression that's well-treated so, so it's complex, but yeah. And then sleep apnea. Yes. Um, and when you think about sleep apnea, you get two things, right? I mean you, for a lot of folks, they get oxygen desaturation, some mild hypoxia. And one of the parts of the brain that's most sensitive to that is the enter rhino cortex and hippocampus in your temporal lobe, which is also one of the first places that Alzheimer's disease unfolds. So again, like an opening the door for a pathological process, less so for treated sleep apnea, um, you still get the sleep fragmentation sometimes, which is the not getting into deep state restorative sleep. And that can be a little bit for cognition, but likely it doesn't confirm the same risk. Good question. Absolutely. All right. I think, okay. I'm going to squeeze on one more. We're trying to get as many as we could, and I appreciate everybody with all the questions I'm going to squeeze one more in here. Uh, Sheila wants to know what are your recommendations for those you serve, who are not mobile and in a wheelchair, do you think breathing exercises can be comparable to the cardio that you recommend? Speaker 1 00:47:56 That's a darn good question. So we work with, we work with a lot of folks who are mobility impaired, and I looked at my rehab colleagues like my physical therapists, occupational therapists, you know, for, is this somebody who could do the arm bike, right? So you basically, you want to get the heart rate up and doing that. I mean, doing that, being stressed out is not the right kind of thing. I'm doing that by restricting or otherwise changing your breathing might not be the right thing either. Um, but you know, I, I looked to water-based, um, activities. So even walking and water, which offers a fair amount of resistance, um, depending on your age, you know, we're not talking about heroic heart rate levels. These are levels at which you feel like you're going to pass out, or, um, it's a brisk workout and getting creative about how to do that. When somebody has impaired mobility, you sometimes need to lean on your other colleagues who are crafting and have some suggestions there. Thank you so much for your time. The great work that you do, your team and everybody at the university of Washington for this wonderful presentation today. My pleasure. Thank you for having me. Thanks for the offer. And again, thanks to everybody in attendance. So I appreciate you spending your time.

Speaker 0 00:00:05 My name is Keith . I'm a regional director of sales and strategic alliances with Silverado, uh, the world leader in providing care for those, with memory impairing diseases. Now, whether it's through our innovative clinical models of care, uh, for our residents, our world acclaimed evidence-based nexus program for early stage dementia that combined science and social engagement, or the many partnerships with global leaders in medical and scientific research Silverado is not only committed to changing the lives of those with memory impairment, uh, but through education and by example, eradicating the stigma surrounding all dementias, uh, we're currently changing lives in 22 communities across six States. Our speaker today is Dr. Merdod. Ayati a well-known nationally and internationally in the field of geriatric medicine. Uh, he is a physician, a speaker, an author, and an educator. Dr. IOT is the medical advisor to the United States Senate special committee on aging providing medical advice on aging and challenges faced by the aging population in the U S Dr. Speaker 0 00:01:02 Ayati is an adjunct assistant professor of medicine at Stanford university school of medicine, where he teaches geriatric and internal medicine. Uh, he joined Stanford university school of medicine in 2011, his faculty, where he taught in practice internal medicine and geriatrics at the Stanford internal medicine clinic, the Stanford senior care clinic, Stanford concierge medicine and Stanford Stanford executive medicine. Dr. Ayati is a member of the ethno geriatrics committee of the American geriatric society and serves as a faculty advisor for the center on longevity at Stanford university. He is a member of the healthcare advisory committee of Northern California and Nevada chapter of the Alzheimer's association, and is a geriatric consultant on aging research projects at Sri the Stanford research Institute international, Dr. Ayati is the editor in chief of the journal of general medicine open access and is the co-author of paths to healthy aging. He is the founder of the Bay area, senior care society. Dr. ADI, I want to say thank you so much for joining us today and that we're all excited to hear, uh, your presentation. So thank you so much. Speaker 1 00:02:04 Thank you so much. I appreciate it. Uh, gave for the warm introduction. I'm so pleased to be here and, uh, again, um, it's, uh, wonderful that we can actually connect this stays through the visual and, uh, we can see many peoples, uh, as well, and they can actually get their education through this new platform. Let's talk about, um, natural daylight and the main thing we wanted to talk is about sleep. Um, and the reason I want to talk about is sleep because the daylight is part of the sleep pattern, and we need to learn a little bit about the sleep of physiology, uh, till we are able to understand what does it mean with, uh, uh, brain circadian rhythm and the rest, uh, before I wanted to start, I have to say that I don't have any conflict of interest, um, about the topic that I'm talking right now. Speaker 1 00:02:53 And, um, again, I'm not getting paid by any pharmaceutical or biomedical, uh, uh, by technology company or biomedical related to the topic that I'm talking right now, sleep change. It's one of the topic that we want to talk about it. And the main topic that we're going to talk is a brain circadian rhythm. Uh, why do we need to sleep? And the change of sleep as we age, and some strategies to improve the sleep, which more effects on dementia and also cognitive impairment. The main thing that I wanted that you, we all learn is about brain circadian rhythm, exactly what we talking about daylight and why the light is important. Part of that, some of the questions that we able to answer at the end of this topic is some of the major, uh, simple things that people talk about it. Like, for example, why exercise help us to sleep better? Speaker 1 00:03:43 This is always a question that a lot of the patient asks that what's the relationship between exercise and asleep. Why light is very essential for brain function and why is sleep necessary to, or a standard physiology for body and why? When we come older, men become older, we have more complaint about asleep and why a lot of the people they're not able to sleep in nursing, home and hospitals, and especially in facilities and the people with dementia have more problem with the sleeping, why it happened. Now, the first things we wanted to say, some opinion about the sleep. And I just want to share with you some of the opinion that people had, the famous people about the sleep. Um, the one from Ernest Hemingway's, I love sleep. My life has the tendency to fall apart when I'm awake, you know, and the other one is due to sleep. Speaker 1 00:04:33 I know we had a problems when I was younger, but I love you now. Um, Dalai Lama says sleep is the best meditation, which is true. And there's also a very funny, uh, thing set of sleeping, um, is my drug. My bed is the dealer and my alarm clock is the police. Now w the first, before we wanted to start, I wanted to say the biggest lie that happened in the history of human was this, uh, um, a statement then early to bed, early to rise, make them and healthy, wealthy, and wise. That's not true anymore. We know that people actually are sleeping more. They have much better brain function, and it does it not necessarily the people actually sleeps less. Um, it means they're a smarter. And, um, actually the sleep is one of the major, uh, Trump pubic things for happened to the brain, which we're going to talk about it as sleep is a very important part of the life. Speaker 1 00:05:28 And it still is a mystery. We have half of our life is spent in the, in the sleep. For example, if somebody's age, I mean, this days is very easy to everybody age, till nine years old, we almost suspend Tony three years of her life in a sleep cycle, which is a very, very important part of, or for life when it's, when we have a sleep technically or body gets paralyzed. Um, and we're eyes is still moving and, uh, we still have a feeling of flying and, um, and kind of like a front of the, they call it approach to frontiers of debt. This, these are from, um, uh, Freud, actually the centers every day, every night, or brain go to a startling, uh, metamorphosis, which is true about the sleep is amazing part that why the brain does that. And I'm going to explain to you why, because then we can have the connection between the light. Speaker 1 00:06:19 And we are always, I mean, this is, this is based on a history that why we are doing all of these things in, during the sleep and why. And there's just should be reason. Now, the reason that we know it's about probably one of the things that I want to say this gentle man you may hear about. And he just recently passed away Dr. Damon. He was the father of his sleep medicine and, and he was actually working at Stanford. Many things we know about the sleep brain, circadian rhythm is actually because of his work. Um, after he became semi-retired, he started to writing newspaper and the books, one of the books that actually made was asleep. Walk with me that it was a very nice movie that actually based on what, what, what is the experience about his sleep? I encourage you, if you wanted to look at it's kind of like a comedy, but, um, it's, it's kind of like given an idea of what does it mean to the sleep cycle? Speaker 1 00:07:11 I just want to quickly talk about it, cause this is not a topic that we're going to talk about it today, but I wanted to tell you about this topic because, um, this is the sleep cycle. It is important to understand the sleep cycle. We have two sleep cycle. Overall. One, one is sleep cycle that we have it's non-REM, which is we call non rapid eye movement sleep. And the other one is rapid eye movement sleep, which is we call REM. Now every time when we go to sleep, like, for example, if you're sleeping at 10 o'clock at night, we go to the non REM and one REM cycle, which usually takes around 90 to 110 minutes. Like, for example, if you start a journey and 10:00 PM, we're going to go around like almost around 12, 12, 1230, or maybe 1132, this cycle, what happened is we go for stage one, two entry, which this three stages are non REM sleep. Speaker 1 00:08:04 I'm just circling here. Now during the, the stages we get first lightest sleep or muscle brain activity decreased, we go to stage two and then our I've movement and muscle activities stop. And the brain has a very, very slow wave at that point, technically in non REM sleep, especially a stage one, two and three, we are in a very, very deep sleep. Then we go to this cycle, which we call rapid odd moments suddenly are hard to start to increase the rate. The rate to breathing is start to going up. Blood pressure is going to go up and body is paralyzed, but what we see or all is move so fast. And we started to have dream. Every cycle is around 90 to 110 minutes. Now we may wake up between cycle. Some of us, we would go to the bathroom. Some of us, we may come back again and we, if you're, we move from one cycle to other cycles so fast. Speaker 1 00:08:59 And then during the denied, we have like a three or four of these cycles, which is going to be six hours or seven hours of sleep. The more we go toward the morning, we have more I'm asleep means that technically Remy sleep is the time that we wake up in the morning. And sometime we have some anxiety because it's still, our heart rate is elevated or, or, or, um, or respiratory rate is increase, slow wave, which is the stage one and two entry. It's a very, very deepest sleep. Whenever you don't asleep for a long time, like 24 hours, the first thing happened. You find a bed even don't want to change your clothes, or you just go and jump to the bed. It is a very, very important because it's very, very restful and what we see that or vegetative body function and peripheral vascular tone, significantly decrease. Speaker 1 00:09:50 This is a very, very important part because our blood pressure drops at this point or respond to rates is going to be, we'll be breeds less, more slower. And we have a very, very basic mature, uh, metabolic rate at that point. And that's really, really important and very close to coma. I mean, even if the external is, um, noises may not waking us up when we are in a non REM sleep, it's a very, very important to maintain our immune system, to regulate our body temperature or regulate or blood pressure or moods and, and many other things. The cycle of his sleep is more important than food. And technically we can die by, um, uh, sleep deprivation, but it's still even, we are a star of the food. We still can make it four weeks, but as sleep deprivation can kill us. If we don't get non-REM asleep for period of time, because our body technically entire physiology depends on this cycle. Speaker 1 00:10:49 When we have remedy, which is a paradoxical sleep, which I S I told you that, um, when we have like an average, every minutes, we go to this REM sleep, which is five to 30 minutes. And then the person is going to be, um, when the person is extremely sleepy, we have less REM asleep, more non REM sleep, non rapid eye movement, which is more deepest sleep. But when we are having more naps, for example, or we're really not very tired, then we have more REM sleep. And this is very interesting. No REM sleep is a very interesting time because it's exactly the time that we have all our dreams happen. We have active bodily movement, which is very interesting, but what happened is, as I explained to you, that we wake up in the morning with Remy sleep. What is very important that we need to understand in REM sleep, we need to have our muscle tone to be decreased and depress. Speaker 1 00:11:45 If it's not happened, then we are going acting out every single day teams that we have, um, during the sleep time. And this is why some people, you probably hear, they have like sleepwalking the reason they're asleep walking, because they don't get this paralyzed after muscles. And then they start to acting off the dreams. If you don't get this depression of the muscles, then we are going to be extremely moving during that time, as I said, or as far as you rate is increased heart rate, and this is all reaction to the dream. No, it is so important. I said, why our muscles needs to be paralyzed because otherwise we're going to act up every single dreams that we have. And one of the problem that we see in elderly and some of the geriatric, uh, complex situation like people have Parkinson's disease or Lewy body, or the people have Alzheimer, they have REM sleep behavioral disorder. Speaker 1 00:12:37 Does it mean that during the REM sleep, they're acting out their dreams. And most of the time there's a partner in the bed and one partner is kind of heating the other one and that's exactly happened. Um, and, and, and again, the same thing we have is, is all about the dreams that we have, um, during the, the remise sleep. Well, the most important question, which I'm actually going to go through that, that why the light is also going to be important, why we are, or brain is active or shut down. The answer is bore. Brain is extremely active, especially during the sleep. When we do the pet CT scan of the brain, as you see the red area here, um, in the, in the brain pet CT scan, you can see easily that we have, we are very active brain. Actually, when we talking about REM sleep, right? Speaker 1 00:13:29 The reason is that we have increased optimism capitalism of the body. Yes, it's so important. We have lots of things that happen. Like Freud says about the Ram is the time that we all go mad. We can have psychosis, Hollister nation. We can talk during this time. A lot of people says the time to connection to the gods. Um, and, um, it is exactly the time that we have chaotic firing of all neurons and, uh, many of, uh, and for entire, again, the human is the time to sexually. We actually going to be activated. Um, and, and even for women or men, they're both the same and it's starting from limbic system, this is going to happen. Now it comes to the very important question. When our brain is very active during the sleep, then why do we need a sleep? Should we just be awake and why the brain needs that the time of activity? Speaker 1 00:14:22 Because what happened to them brain? Exactly. The sleeping tub. Cause we for retired brains getting rest during the sleep, but we know that's not true. Brain is very, very active during the sleeping time, why we need to do that. And what's the benefit of asleep. Yeah. And that's the question is going to come here. This is the guy, I don't know if you knew him, but this is Randy Gardner. He was a very famous guy that actually it was who was able to be awake for 264, four hours, which is 11 days and 24 minutes. That was part of the study. Dr. Devin was part of this study. The study was done in San Diego and they technically, they didn't use any assimilate, no coffee, anything in 1964. And they're continuously doing the electrons follow gram of his brain, checking the blood pressure, do EKG and see what happened to Randy. Speaker 1 00:15:14 After that amount of time after Randy, some of their people, they able to broke the record. I think somebody made it till 12 days in South Africa. But again, what happened is a very important things of what happened to him on the second day is Randy, his eyes are stopped to focusing his stop, identify the object by touch. He was not able to say, this is hard. This is rough anymore. He'd become very moody on coordinated. And he becomes half Holocene nation. After that, he has short-term memory loss. I wanted to really pay attention to this part because that's very, very important to understand it later. And then he started to have very paranoid psychosis who complete, he recovered completely. He's still alive. And, um, um, it doesn't have a longer and damage, but we were able to learn why many of psychosis feature memory loss, even so sorry, touch eyes. Speaker 1 00:16:10 Everything has been complete, completely gone while he was asleep. No. Now back to physiology, when we talk about the sleep, there's two, there are many, many neurotransmitter in the brain is important, but there's a two signals are very, very important in our body to understand about the sleep cycle. One of them is atrazine. One of them is melatonin, which you heard about that. These are signals from our body, the signals from our environment to tell our body is tired and ezine is the production of the muscles is built up during the day in the brain. And is technically what we call is internal energy store. If you do exercise, if you use your muscles, you build up the animals in and add it as in is the reason that people get a snip pressure. As you see in the picture. If I, when the front of monitor, when I'm talking to you, if I have my eyes are getting closed and I just keep sleeping, that means I have a lot of animals in my brain. Speaker 1 00:17:09 Okay. Adam is in coffee, coffee and caffeine, which we all taking in the morning is technically, as you see here, right? This is the admin cuisine, and this is going to be your, your, your, your caffeine caffeine, technically, uh, block the adenosine receptor. And doesn't let the ad and Rozene to sit on that, but it's going to be limitation. Now, the first question that I said in my topic, why exercise make you sleep better? Because when you use your muscles, you produce more ad nauseum. As a consequence of that, your brain is going to be more sleepy at night, and then you're able to sleep better. But what happened during the sleep time, there is a system in the brain called glymphatic system is produced by a spinal fluid, goes to a brain and a start to clearing and cleaning your brain. As a consequence of that, then you're technically able to get rid of ad nauseum. Speaker 1 00:18:03 And then when you wake up in the morning, next morning, your brain is free of Adam cuisine and you are fresh. If you don't asleep, you still have some residual Adams in from the day before that's, while you feel very groggy, you feel incoordinated next day, you are not able to concentrate very well because you still have residual ad nauseum in your brain. It is so important. The brain during that cycle, that we talk about it, the start to cleaning through the spinal fluid. This adamancy. The second thing is, which is a subject of our talk today is about melatonin. Melatonin is approaching is technically as a brain. Circadian rhythm is the which technically help us to understand the master clock in the brain. This is the master clock. This is the time when we look at, okay, this is the daytime in California. And this is the nighttime responding to the light was not only for us animal plants and microbes that all have some brain, the master clock in their system. Speaker 1 00:19:00 Even pious has it microbes, have they have it. But again, for us is a melatonin is the one is telling us what happened. I want it to bring their attention here to this picture is a very busy picture, but I want to tell you, what's going on here is the light. As you see here comes through your eyes. When it comes to your eyes, it goes from the lens and then go all the way to retina, which is here in the red. Now you're processing the lights and the lights goes to the place here, which we call super nucleus. Um, again, SCN or super Christ, Marik, nucleus. This is the place in the brain that has started to processing all the lights that happen. And as a consequence from that place, it goes to a place in the brain called pineal gland. And from pineal gland, we produce natural melatonin here in the blood stream. Speaker 1 00:19:50 Then light go to eyes, go to this place, go to the pineal gland. And we have natural melatonin in the body that is telling us that this is the day. This is the night. This is the time to sleep. This is the time to be active. No, I'm honored to answer some questions here that you may have here. When we getting older, what happened to us? Many of us, we have cataract or lens are not going to be very clear. That's why we have a problem with getting lights or retina. Many people they're starting to have degeneration in the retinal area. That's why they're not able to process light very well. This is one of the reason as we're getting older is sleeping is going to be much difficult for us. When it comes here, we get calcification of this places, Supercross, Marik, new clothes, get calcified as we're getting older. Speaker 1 00:20:38 And this is why we have a hard time to processing, to sleeping cycle. And I wanted to tell you something, the people getting dementia, especially like for example, Alzheimer's dementia. What happened in people with Alzheimer's dementia, they get a lot of protein that they come and cut displaces. This connection's going to be cut, like from here to here going to be caught. What else can cause that a stroke that people have a stroke, they have cutting of the system. There's not able to light process very well all the way to the pineal gland, Supercross, MarTech new clues. And that's what we're not able to produce natural melatonin. That's why we're not able to understand circadian brain rhythm wearing wow. Melatonin. Technically is a time. Messenger is telling us, this is the day. This is the life is producing. Technically during the day we get the light and evening melatonin comes to the bloodstream and then it start to getting to the system and telling us that this is the day. Speaker 1 00:21:38 This is the night. Now it's so important because I wanted to tell you this cycle, which is you can understand what does it mean now? Let's just, just start from here. Let me just back again. My pen here, let's just start from nine. O'clock imagine that you are in California. I mean, we're now I'm talking from California. It's like in like nine o'clock is dark and melatonin. Start to comes to my system. What happened is melatonin as a time is going to go tell to my bladder and my intestine area that please stop functioning. If they don't do it, we're going to be all night in the bathroom. This you can see here, the bowel movement is stop. We're going to go to deepest sleep and a two o'clock in the morning. We're doing very deep sleep. I will tell you, melatonin has the converse effect with the body temperature at four 30 o'clock in the morning, we feel extremely cold, but melatonin is high or body temperatures go. Speaker 1 00:22:33 Usually when we start the night with the blanket, uh, we put the blanket on the bedside, but in the morning we need the blanket. We have to put it on. Cause we feel extremely cold. And in the morning when we have a sunrise or blood pressures, start to rise, melatonin is start to stop at seven 30 in the morning between six 45 to seven 30 is still, we have some residual melatonin in the system. This is why people are very, um, drowsy is still in early morning. One of the reasons we have the highest amount of accident in the highway is actually early morning because people are still very, very sleepy. Um, and again, eight 30 in the morning when the melatonin completely stopped, we going to have a ball movement. The start we have, um, high alertness at 10 o'clock. If you want to do any examination, this is the best time tanks to key, to, to coordinate this time for conference because 11 o'clock is the best time that you can learn everything. Speaker 1 00:23:26 And then afternoon, we have the best coordination, fastest reaction time. If you want to make any financial decision, this is the best time. And you have a very high cardiovascular effectiveness in the afternoon. This is why a lot of people talk about it is the best time to do or cardio exercise in the early afternoon, like before, like around like 5:00 PM, 4:00 PM, because our heart is in the maximum function, not very early in the morning, and that's kind of things that it can help us to understand or body. Um, uh, this is us. This is 24 hours. What we call it, natural daylight brain circadian rhythm, that we are going to talk more about it in the next slide. As we said, that melatonin is going to up at nighttime and then it's going to have a drop in there. And then based on that, we have different kinds of people. Speaker 1 00:24:14 Some people are advanced sleep phase disorder. Now what happened in this people, as you see here in the picture, um, their melatonin is actually instead of going up much later at the night, it goes up much earlier in the evening, like for example, 6:00 PM, 7:00 PM. They feel extremely sleepy much earlier. And their body temperature is kind of like dropping much earlier at that trauma. Two o'clock two o'clock in the morning. This is why we call it morning type people. The people wake up between two o'clock and five o'clock and they usually go to sleep between six to 9:00 PM. As we getting to middle age to our elderly, we are this type of people, melatonin res much earlier in our body's system. I have a point about this for you, which I'm going to share with you the other, uh, as you probably say, the core body temperature drops, we feel as sleepy. Speaker 1 00:25:06 And again, we are have a gradual progress through the age, and this is why many of people, when they get to middle age toward older adult, they actually wake up much early in the morning. And they're always complaining about that. They have the problem to fall back in sleep. On the other side, the people have delayed the sleep phase disorder, delayed sleep phase disorder are the people that are two hours. Usually late. There are evening type people. And most of these people are teenagers, teenagers, and young people. As you see here, the young people, the melatonin is not going to go up after midnight. And the core body temperature is going to drop much later. This is why they wake up around like 11:00 AM or 12:00 PM. And this is the complainant, always the parents about younger teenager, but this is a very normal sleep phase disorder and family history is going to be one of the tanks that it's very strongly contribute to that. Speaker 1 00:26:01 Now, based on that people have a different cycle. If feed imagined that normal people or the people there, like, for example, I don't call it normal anymore because this is not true. But if somebody like, for example, asleep at 9:00 PM, wake up at 8:00 AM we call it normal? No delayed is the phase disorder or the young people and teenager, they wake up 2:00 AM they sleep at 3:00 AM. They wake up 12:00 PM. And as we're getting older, we sleep much earlier at the evening time. And we wake up at two or three o'clock in the morning and we're not able to fall asleep. We talk about this tree. Well, who are these people? They're sleeping tonight. They wake up sleep two hours. They wake up people with dementia. These are exactly the, what we talk about it because of the blockage on the nervous system in the brain, they have a very sporadic sleep cycle. Speaker 1 00:26:53 This is what we call it. Irregular asleep, waking with rhythm. The other one is non 24 hours of sleep, wake and rhythm. This is exactly going to be some people with cognitive impairment neurodegenerative, but this is going to be a very, very good example. The wife physiology CLI people with a stroke, people with dementia, they have very sporadic cycle of his sleep. And this is a very common mistake that I see a lot of time that people trying to give them medication to make them asleep eight hours straight at night. The people with dementia, that's absolutely a wrong practice because the brain is not at the situation that they are able to sleep for a six to eight hours. They are going to have a sporadic the sleep cycle, and they're going to be awake. They're going to wander. They get their Walker. If they're able to walk walking around the house or facility and they come back to the bed, they sleep for a couple hours. Speaker 1 00:27:43 They wake up. This is totally normal physiology for the brain and any, um, a sleeping medication for them is really not going to be helpful. But the life of human has been changed because we have a lot of the artificial lights in our system, TV monitor computer. When we look at the history, we're been technically living here, cave into darkness. And then when we have the agricultural, um, life, then we start to do ag agriculture during the day. And then nighttime, we, it goes to the tour houses and the darkness, and then we sleep. I wanted to, but because of this gentleman, Thomas Edison, uh, he waited the darkness and we have a much brighter, um, environment. That's makes the brain to become confused as well. And that's something that we have to pay attention. I can tell you before I actually went to Stanford, I was just practicing in the central Valley. Speaker 1 00:28:39 And most of the people have been farmers there. Uh, personally, I have to say that I've never seen any farmers have a complaint of a sleep problem in my life because they leave with the natural daylight cycle. They wake up exactly at the sunrise day work during the sun, they get the exposure to the sun and light and they go and asleep at the evening time. And they actually work very well. Um, the brain cycle is really adjusted to melatonin and natural, but because we are in the city life, we have tons of lights right now, as you probably hear. And I just reading an, uh, a year ago, uh, there was a very interesting article in national geography that when they look at the, from the space shuttle, the planet is very bright right now because of the lots of artificial lights in the cities. Speaker 1 00:29:28 And that's definitely is a toxic for brain because brain doesn't like to be under the light. And that's one of the things we talk about circadian rhythm, it's so important or body function or temperature, hormonal effect, obesity, depression, bipolar, everything is related to our circadian rhythm. We know it. We know that people may get more metabolism problem or diabetes, even in the study of Donna in rats and mice, that are the mice that the eating later off the night, or they have the habit of eating any time. Instead of like the mice that they have, the specific time of the day, day eating, and a specific time to stop eating, they are less likely to get diabetes, but the one, they have a sporadic pattern of eating the actually get more. It definitely affects off the vascular system. We know that, um, this, so Kenyan, brutalism, and not as sleeping, it affects of high blood pressure diabetes. Speaker 1 00:30:22 We know the story that a gentlemen in the 2014 world cup soccer for world cup, he died of the sleep deprivation after 24 hours of night slipping. But again, some people have totally a sporadic pattern, right? Um, this gentleman has the 10 hours of each night to sleep and he he's getting more hours of asleep. And he was a very smart man, but the, um, Tesla had a very interesting pattern of his sleeping, sleeping, couple hours. You wake up a steep couple of us, but when we average is asleep, it was sleeping for 14 hours a day, but it was very sporadic, but he gets what his brain needed at that time. But it's so important to understand the why the snip is important for memory, because we talk about asleep and in the Randy experience that he actually had a very short time, as we know here, the steep is the most important it's in part of reconstructing of a memory. Speaker 1 00:31:15 And it's a time that anything we get into short term memory goes to the long-term memory. And this is so important because hypo Campbell area, this is the place that you see here in the blue collar. This is the place that is responsible for short-term and also, or learning short-term memory and also learn, no, this is the important part that talk about declarative and procedural memory. Okay. Now, when so many has like Alzheimer's dementia, what we see here, MRI that this hypo Campbell area gets shrink, gets actual thick. And this is why it's so important to understand it. When we talk about declarative memory and procedural memory, this is exactly what we talk about. Declarative memory is technically on the temporal lobe is about facts and is about events. Like for example, you remember the anniversary, remember the birthday procedural memory is a skills and habit and need for this to part, the sleep is so important because this is the time that you moving from your short-term to long-term like, for example, today, anything I telling you, it's a, it goes to a short-term memory, but if you sleep tonight, then tomorrow morning, you wake up and say, Oh, there was a speaker, Dr. Speaker 1 00:32:27 Yachty. He came on board. He talk about the sleep and he's, he told us many times if you don't sleep very well tonight, you may not able to remember the details that I, we talk about it. And these are the memories that we definitely need the sleep for, for the cycle. As you see here, uh, which is very well explained when we are awake, everything's come to hypo capital area. As you see here, sitting there, but what happened during the sleep everything's get organized and move to the deep layer of the brain. And when you wake up in the morning, your hypo Campo, area's completely empty. You're ready for the new information. And what happened to your deep side of the brain is everything is very, very well organized. You see the colors, blue are together purple and the pink saw together. And this is exactly the reason that we have this. Speaker 1 00:33:15 Um, it is so important. We all was saying that it's a common experience of the problem. Difficult at night is resolving the morning after the comedy of his sleep has worked on it. That's absolutely true. Um, I just want to say that it is so important to understand that your immune system is really related to the sleep cycle. We see on this study, the people that have poor sleep, the influence of vaccine is not effective in them, and they are having more potential to get cold as well. But if one of the things is about light therapy, because light, if we cannot get the sunlight, which again, we are in California, we were lucky, but in many people that they don't have a light. They brought the bright light therapy. First started from people in UK and a Scandinavian country because they really didn't. They don't have the light and most of the, or most of the year, but what happened is that the, they developed the sunlight or light box. Speaker 1 00:34:08 And then what happened is during the sunlight and light box, they're starting to give them the light at that time for people like the teenagers, they better to give them in the two hours early morning for people older adults, they better to give them advanced, which we call advanced asleep phase two hours at the same dose in the evening. But then they have to do routine eye exam as well. But it has a lot of effect bright by terribly. We see in people with dementia has effectiveness on depression and anxiety and in depth in many, a study that we have so far, the best time for a sleep, uh, for, for bright light therapy. It depends on what the problem that you have for teenagers. We need to make the melatonin to be secreted earlier time. That's why early morning light therapy. It's going to be the best time for people or most of the older adult people. Speaker 1 00:34:59 Most of my patient in geriatric, because they have a problem that they feel asleep in the evening and they wake up two or three o'clock the best time is later afternoon. And this is so important, which is one of the advice I give it to my patient. If you really want to, to adjust your asleep, you better to have the song glasses till noon and do not go outside. And then when you go outside is early afternoon. Technically when we get retired, we all getting out in the early morning, and this is the biggest mistake that we do because when we get light in during the morning time, technically where melatonin is going to be secreting earlier in the more in the evening, the best thing for this population is wait till afternoon stains side to stay indoors early afternoon, go outside and get the maximum sun and light in the afternoon that going help. Speaker 1 00:35:50 And if they want to do early morning walk, they should use a very strong sunglasses to not getting light in the daytime. And then later afternoon walk with all sunglasses to getting the maximum white, the effects of the anxiety and light is so important to people of dementia. We see the people with vascular dementia. There's a lot of the scores that we see that even turning minutes exposure to the morning light has helped with anxiety as well. We have of goodness study from darling and colleagues that showed the people with Alzheimer's dementia. They actually have very effectiveness on aggressive behavior are fortunately many of our, uh, memory care units. And again, there, most of them is indoors. We have very limited a memory care unit that they have a very big places and they can go outside and they get a good morning light. Some of the tips is the light is important. Speaker 1 00:36:42 If you do the light therapy for Alzheimer's dementia, we're not going to see effect right away. It takes maybe six months to see that. And, um, and again, um, a lot of people, they say windows, windows is really not important. If you are two, three meters away from the three or four meters away from the windows is really not. You really need to have a good exposure to the light. And this is exactly answering the question to why the hospital and nursing home are the worst place for sleeping because of the artificial light that we use it in a nursing home in hospital. I want to quickly just say about pharmacologic, because you may ask him, this is not a topic we've got to talk today. Maybe another time we can coordinate for have this topic about what are the sleep medication that we use, but one or two, say something that, um, um, only time when we use them, when we have, um, chronic insomnia, they are not responding to behavioral therapy or does the acute, the stressor that we need to use the sleeping medication, always the smallest dose. Speaker 1 00:37:44 And we also have to really be careful about adverse risk effect, because what happened is that it's so important that we know, and there are different types. There are short acting to help to fall asleep. There are intermediate acting to helping you to staying asleep. This is so important. There's lots of them. I don't want to talk about them. That's not a topic for today, but there are lots of the medications are available and they're also carrying the risk. As you see here, there's lots of risk is here with them, but it's so important. I'm not saying that we do not prescribe. We should be vigilant. We should be smart. We should really find the right person. As I said, like for example, somebody with dementia, prescribing a sleeping medication is a wrong way to go because it's where are you? Where, where did this? Speaker 1 00:38:27 Where is this medication is going to go? In which receptors it is so important that the physicians or practitioner families altogether come a good model of what medications do we need to use. And that's kind of like a needs of skills and some knowledge behind that. Um, again, uh, um, there are maybe effective compared to placebo. Um, but again, don't forget the most of this study is a pharmaceutical run by death. But again, just want to say that the side effect is there and we have a loss of mortality, cancer, many other things from this side effect of this medication and the long-term use of this medication is always caused the habit because we've developed tolerance. This is a question that we don't know there, why this has happened, and this is something we need to understand. And some of the medication, like for example, about, um, watch, we call men non benzodiazepine, receptor agonist. Speaker 1 00:39:24 So it can be in the famous one. We know does increase with the risk of fall and, uh, the same thing as like lorazepam and the use of benzodiazepine, or even like non benzodiazepine, receptor agonists should be limited to less than six months because long-term use associated with definitely cognitive impairment and dementia melatonin that you buy, which is, uh, um, from, from outside maybe effective, doesn't have the same side effects that all non benzodiazepine, but it's very different people. People have a very different response to melatonin because we don't have really a right physiologic dose for that. And this is why we have this, which depends on the people. How much did those have this, the medication that they needed based on the seral melatonin. And this is why it's kind of like an artifice sleep. And also even geriatric when it comes to what is the right dose of melatonin, somebody needs it. Speaker 1 00:40:20 But for example, many people, they may need a 0.1 milligram of from electronic. If you give them more, it actually makes them more groggy and more side effects. Maybe some people need 10 milligram. Maybe people need one milligram. This is why even for external the location settlement of 20 and, or, or, or over the counter, we recommend to start with the tiny dose and then gradually increase the dose to, to see the effect I wanted to just wrap up here that it is so important to understand is sleep is not a dizziness. If somebody sleeping is not Nisa, somebody is, is, is sick. It's means that the body needs to sleep, but we have to also understand about over sedating and over sleeping as well. It is important to understand change in the circadian brain rhythm. I have to say, if everybody understand his own brain, circadian rhythm, natural daylight, and how we can use the sun and the daylight as orthopedic effect, then you're able to understand your own physiology much better. And there's really no safest sleep aid medication at D. Speaker 0 00:41:24 Wow, well, Dr. Roddy again, thank you so informative. So much information to digest. So thank you so much, uh, for this amazing, uh, presentation, uh, lots of questions here, and we're going to do our best to get through as many as we can. Uh, I'm going to start first of all, with, um, would you consider it to be unhealthy or a cause for concern, if a person is in bed for eight hours of sleep, but wakes up six to eight times each night for about three to five minutes each time, would that be something that would be cause for concern? Speaker 1 00:41:54 No, but what is the reason it's so important if somebody is saying, uh, it's true different situation. If somebody is staying in bed for eight hours, but has interrupted asleep. If my understanding is that person wake up for six or seven, that means the person really doesn't get enough necessary sleep very well. Number one, we have to find why that person is actually wakes up six to eight times at night or day, whatever the person's cycle is. There's definitely a reason for it. They are that person doesn't get a very good maintaining sleep. Most of the people they have to go for urination. That means that if there are using, uh, there's a medical problem, that they actually, they have to go to the bathroom or they using medication that actually makes us interrupted asleep. This is the job of the physician. This is job of geriatrician to review their medication list and make sure this is, or even the medical problem to see what's the why, the reason what's the reason the person has to wake up six or eight times at night and they'll go to the bathroom. What is there any underlying neurological diseases there? Um, but yes, it's, if you just stayed eight hours in the bed, but we have to go six to eight hours. No, that's not healthy. That means there's something wrong. But if somebody is really asleep for eight hours in this thing that I just say congratulate to that person is very lucky as a good brain able to do that. Speaker 0 00:43:15 I'm envious of that person. For sure. The next question is, does one produce more melatonin during REM cycle versus the non Wren cycles? Speaker 1 00:43:24 No, the melatonin produced during the daytime and then it relieves at nighttime technically. Um, we get the light during the day we get the process and nighttime be producing the melatonin. Melatonin is kind of like a steady goal. It doesn't matter what non REM REM asleep anyway. And, um, and that's, this is my understanding of question is right in middle of 20, it doesn't do anything with Rehmann non-REM is released at evening time. When the, whenever based on your local area, as far as like a sunset it's released, whenever it's going to be dark outside. And then this is the time that your brain has start to feeling that you want it to fall asleep. Speaker 0 00:44:05 Okay. Next question is talking during the sleep, is that as, as somebody who talks during the sleep, is that something you learned about, or is that a sign of anything or is that normal? Speaker 1 00:44:15 It's just sign as, as the, that person during the REM sleep is not able to suppress the speech muscles. And again, as we said, we all add some of our, some of us were acting out or dreams at night. The people also sleep talking is the same problem. They talking in the dreams, but they're not able to paralyze their speeching muscles. And this is very genetic. Um, a lot of people have a degree. They also get this as well. And then the, they talk during the sleep. This is nothing wrong about it. This is the way that they are. This is the way they are. And it's very interesting. Sometime they even tell all their secrets at night during the sleep, if they have the partner is someone they can learn all about their secrets at night. Speaker 0 00:44:58 Good. The next question is what is your suggestions of family caregivers that are caring for their family members with dementia and the dementia patients or the measure family member is waking the family members up at night during their natural sleep patterns. What's your recommendation for that family caregiver? Who's in a situation Speaker 1 00:45:15 Question. I mean, the problem is that most of the time we, we wake them up for, uh, changing, like for example, changing the pool up or something at nighttime and technically makes the interrupted asleep. Is it the question is about that family caregivers. I define my understanding is that, um, first of all, the people with dementia, they, if they are very lucky, they may, they may be asleep, is straight and they don't have this sporadic, his sleep pattern, but we always recommend to minimize any instruction at nighttime. And this is the same thing for memory care as well, to any interruption at night, as much as we can, um, to, to let them their brain again, with the dealing, with all the damage and broken system to kind of like adjusting itself with the sleep. Um, and this is why I know a lot of people are very, um, um, sensitive about it. Speaker 1 00:46:08 But again, I completely understand because sometime when they have bowel movement and urination, it caused a urinary tract infection as well. But as far as we do, I will say the same protocol that we use for the babies. We try to not really make the lights on. It's not making a lot of noises is try to do it as much as the slowly and quiet that we can. I've observed it in many other places in memory care, they do this protocol and they try to be very calm and quiet when they're doing this ADL's as far as if he can do it and makes the situation to not make their brain to be awake, because otherwise they're going to be awakened agitated at that time. Speaker 0 00:46:46 And, and for the, let's say for the person who's still at home, maybe their is caring for them. And now that spouse is not getting a lot of sleep themselves due the interruptions, what any recommendations or thoughts for that person and how to Speaker 2 00:46:58 Regulate them? Exactly, Speaker 1 00:47:00 Exactly. One of the main major problem for many, um, uh, people, um, um, that, because the loved one has dementia and doesn't have a very straight to sleep pattern and wake up multiple times at night. And, um, it's, uh, sadly I have to say, this is the time that most of the time the family, uh, decides to, uh, move the loved one to the facility. I mean, as I'm saying, cause a sadly we're not, but this is the time that really cannot do that because it's very difficult and caring of the loved one with dementia at home is very, very difficult. Especially night will be the time that they're going to have a very, as, as music, explain the sporadic, his sleep pattern, not let the other people asleep. And, um, and or maybe the time that they need to find someone to come and help them at night. Speaker 1 00:47:49 Someone that'd be awake at any time when days start to wake up and wanders, be with them to make sure they are safe. And, um, again, some of my patients, they get asleep like, um, two to three times a night, they get a caregiver at home at nighttime and at least at what they have respite to sleep time that they have at least two to three nights a week, they can asleep. And the rest of the week that they can, they know that their loved one is going to be awake and they do that. Um, again, it's very hard because if you give a sleeping medication to family, caregiver, and the loved one has dementia, it's going to be unsafe because they're going to be in deep sleep and they're going to be wandering around. And it it's still in home. Environments can be dangerous, honestly, most of the time for my patient, if there is no any problem, I really, this is the time I recommend to take them to a place, to, to a memory care unit because, uh, at least, uh, especially when the loved one and again, the partner or family caregiver is also in the geriatric zone. Speaker 1 00:48:47 And I'm very worried about their health as well, if they're not able to sleep at all. And th these are the, exactly the discussion that we have with the family most of the time. Speaker 0 00:48:56 Yeah, absolutely. That makes sense. And I guess, uh, the next question I've got Dr. Yachty is, uh, is there a recommended, uh, for the bright light therapy timing? So for somebody who's got, uh, Alzheimer's or dementia and they have sporadic sleep cycles, is there a recommended timing for BLT? Speaker 1 00:49:13 It's a good, good, good question. My suggestion for the people with dementia, I put them in the category is still off the advanced sleep disorder. And I actually say early afternoon time, it's the best time that we do bright light therapy. It's not my suggestion is this same model that they do in the many of the memory care units in other countries in UK, um, in the Scandinavian countries, they do it as well in Australia. They do to Japan, they do it as well. They actually do early afternoon bright light therapy for many of their residents with dementia in their care homes. And, uh, they've, they've seen a good result. They, they even use it when they are getting admitted to the hospital in the early afternoon time. And they see that even in not helping them for three to six months to sleep, but they're more calm. And actually one of the other things that they can see sundowning sundowning behavior, which is exactly the result of the bright, uh, the lack of the lights, especially when the outsides start to become dark. This is exactly the reason a part of the circadian brain rhythm is sun sundowning, which we see in the, in the dementia people that can help significantly with sundowning as well, much better than any medication. Speaker 0 00:50:25 Okay, wonderful. Um, if you are a morning person, uh, what's the best time to get sunlight Speaker 1 00:50:33 Early afternoon. If you are a morning type person, wake up, then you better to not getting out of the house till early afternoon. And probably the best time I will say is going to be after 1:00 PM, try to get the maximum of light between one to 3:00 PM. If you go outside this time, do not use any sunglasses. If you can, if some of the people, because of medical problem, they have to do sunglasses, um, that just make it very limited. And, um, and that, that situation that can help, um, um, uh, a significant, but not during the data, if you have to go outside during the daytime, like from morning till noon or early afternoon, definitely use the hat or the strong sunglasses. Okay. And the other advice that I just, again, we just forgot to tell is about watching TV or computer tend to have the lights can be also confusing for brain. There is also a possibility that, uh, um, um, that they can, they can do, um, um, uh, use sunglasses when they watched a TV. You also look at an, a monitor, dirty, specific sunglasses for monitoring TV also, which can be very helpful. Speaker 0 00:51:43 Wonderful. Okay. I think we've got time for just maybe one or two or so more questions. Um, are there any sleep disorders or patterns that are considered symptomatic or a sign of early dementia? Speaker 1 00:51:56 Are there any specific, I'm sorry, I just lost, Speaker 0 00:51:59 Uh, specific, uh, sleep disorders or, uh, sleep issues that might be a sign of potential onset of dementia. Speaker 1 00:52:08 Very good question. You know, um, there's, the scientists are, um, wandering for many years that is sleep deprivation or lack of sleep is one of the risk factor for developing cognitive impairment and dementia. We haven't find them in neuroscientists. Haven't find that people like, for example, have a sleep deprivation. It's a sign of early dementia, but they know people that they don't have a good sleep pattern is much higher risk of developing cognitive impairment later. And there is, there is possibly that there is this, there are some neurodegeneration is happening to the brain that we're not aware of that. Um, and again, we can not recognize it or finding an image that at the technology at that point, maybe we will find it in the future, but it is, it is important that we understand as of now, if we have a sleep problem, we definitely need to take it seriously and discuss with our provider. And if there's any treatment needs to be done, they can do it, um, at that time. Speaker 0 00:53:11 Wonderful. Okay. What can you say about people who haven't really active dreams like with nightmares? Are there any known treatments for that? Speaker 1 00:53:20 If they have a very severe yes, they have. Um, there are some sort of the medication, which in the category of dopaminergic medication, which we call it, um, again, you just say medication we use for people with Parkinson's they have, but very low dose. Not that doesn't mean the person has a Parkinson, but technically we use a very tiny dose of this medication. If they're active dreams is problematic, or they have REM behavioral sleep disorder, um, um, that is causing a significant problem. Yes, these are the medication that we use. Okay. Speaker 0 00:53:56 All right. I think we can squeeze one more in here. And, uh, for first of all, for all those who submitted questions, apologies. If we can't get to all again, uh, this has just been so informative and Dr. ADI is a wealth of information, so thank you, Dr. ADI, the last question I'm going to, uh, just, uh, throw your way is how does hydration affects sleep? Does hydration have any impact on a person's sleep? Speaker 1 00:54:16 It is, it helps with the good blood circulation. For course, of course it helps with the brain circulation. Definitely. It helps with the clearance of Adam's cuisine, which I explained to in my presentation as well, because you have a better flow off your spinal fluid as well. It helps significantly. Um, however, there's on the other side, if you do too much hydration, you may have to, uh, pay back in the nighttime with going for more UNH. It should be very important to have a balance at what is the time of dehydration. Because on the other side, we see, especially in older people on the other side of the too much hydration also can cause some problems. It is very important, but yes, it is effective, but timing is also so important. Speaker 0 00:54:58 I just want to say I've, I've been, uh, just overwhelmed. There's so many comments coming in. Everybody is very appreciative of the information. It's been very fascinating, very informative. So on behalf of everybody who's joined us today. I just, again, want to say, thank you so much for sharing this very important presentation and information with us today, and for all those who did join us again on behalf of, uh, all of us here at Silverado doc, I don't want to say thank you so much for taking the time to join us today and be with us today. So thank you all. And hopefully everybody has a great night's sleep tonight. Thank you. Bye

Speaker 0 00:00:00 welcome to our Silverado memory care podcast. My name is Jeff from senior vice president of communications. Joining me today is our senior vice president of clinical services. Kim Bostrom, who will help us address the top concerns from professionals, whether to refer to a Silverado memory care community during the COVID-19 pandemic as a gerontological nurse practitioner, Kim has over 30 years of experience serving and treating those with neurodegenerative disorders. Having worked at UC San Diego's Alzheimer's disease research center and the memory center at Seton brain and spine neurology in Austin, Texas Kim oversees Silverados, university affiliations, and also leads all clinical research studies in which the company participates, you know, Kim and I both feel our responsibility as the industry leader in long-term residential memory care is to provide answers to the most common questions and concerns. Families and professionals have caring for a loved one, caring for a patient, a client, or a resident with a memory impairing disease. Speaker 0 00:01:03 Today, we will address the top concerns from professionals, whether to refer or not to a Silverado memory care community during the COVID-19 pandemic Silverado as 21 memory care communities in six States from Newport beach, California, to Alexandria, Virginia, we collected feedback from our top partners in care from leading geriatric care managers, physicians, hospital case managers to referral agencies, care management firms and senior centers. You know, Kim, the first and most common concerns shared with Silverado is around visitation. We're often asked will COVID-19 lockdowns and required safety protocols prevent families from being able to visit their loved ones. And in contrast, will in-person visitation policies make a facility more vulnerable to a COVID outbreak? What are your thoughts? Kim? Speaker 1 00:01:55 You know, visitation is an absolute priority. We know it's necessary to maintain our residents quality of life and we've taken the steps needed to encourage it. However possible that might be by a video chat or an in-person pre-arranged visit. Physical visits can be safe as long as strict physical distancing protocols as established by local and federal authorities are followed as well as the extra infection control protocols that we've put in place at Silverado, which include the use of medical grade kn 95 masks increased ventilation hand washing scheduled, as well as respiratory etiquette. We know that an in-person visit is the really first choice for most families and residents. And we're working very hard to accommodate in-person visits whenever we can do it. Speaker 0 00:02:50 Yeah. The second most frequent concern heard from professionals is around social distancing. Doesn't congregate living we're, especially a large memory care community, make social distancing difficult, and create a higher risk for an outbreak. Speaker 1 00:03:06 You know, COVID-19 impact was felt strongly in nursing homes and in various care facilities, but not all facilities have felt that equally Silverado already followed our own nationally recognized infection control practices and our commitment to maintaining high clinical standards has allowed us to adapt to the latest findings immediately. We have now added, uh, infection control protocols, including universal K in 95 masking and kn 95 masks are more costly, but they're more effective. And that's why we've committed to them. Uh, testing associates extensively, um, as well as developing designated separate neighborhoods for those returning from outside the community, by taking that high level of science-based precautions, Silverado has been able to maintain a high level of personal care without creating undue risks for outbreaks. Speaker 0 00:04:05 So the first two concerns shared by professionals were around number one, visitation and number two, the concerns around social distancing in a memory care community. The third most common concern from professionals that we hear is whether smaller living options are safer. You know, Kim is a smaller facility like a board and care or a group home with a smaller staff, a safer option during the pandemic for my loved one with dementia, Speaker 1 00:04:34 The size of the facility is really not as important as the precautions that are being taken to protect the residents as well as the expertise of the staff. Initially, it may seem that a facility with fewer residents and staff is safer, but the protocols they follow and how closely they adhere to those protocols can drastically affect the likelihood of an outbreak. Additionally, you have to remember that a larger facility is more likely to have a larger set of benefits for its residents. Silverado's clinical team is led by an RN. We have licensed nurses on site 24 hours a day, seven days a week. They're supported by a dedicated medical director and our robust engagement program nexus at Silverado, which is an internationally recognized evidence-based brain health program help give life to someone living with dementia, even during a pandemic Silverado also provides a masters, a trained social worker, which is a huge benefit at this time, particularly because they conduct support groups for our more cognitively capable residents who really have a lot to work through in terms of the complications COVID-19 have brought as well as living with dementia, a smaller facility simply provide those resources. Speaker 1 00:05:59 Um, additionally, one of the infection control protocols that we took early on was to segment our Silverado communities into smaller neighborhoods that really allows us to function as a smaller facility, but with all those added resources, a pandemic requires people to follow infectious disease protocols. And that's very difficult for someone with a memory impairment disease to understand you get questions, like why are you wearing a mask? I don't want to wash my hands or do whatever is required from that protocol. Um, a community like Silverado, especially because we have our dementia certified staff, our behavior management protocols, and that robust engagement is what is needed. We hear so many stories from families that have had their loved ones in other communities who have made the decision to move into a Silverado community during the pandemic. And they report that staff in those other locations had to resort to things like restraining residents with medications or isolating in their room to be able to manage the behaviors that resulted from that person living with dementia, not understanding the current situation. Speaker 0 00:07:17 Well, thanks, Kim. That's certainly some weighty topics for sure. The next concern shared by professionals was around proper protocols and the use of PPE, obviously a big safety concerns. Can you be certain that a memory care facility has the clinical expertise and training and robust enough safety protocols to keep residents safe? Speaker 1 00:07:39 I would say that that is a really important question for anyone to ask any memory care facility they're concerned about or wondering about, I can say absolutely that despite publicized shortages around the country, Silverado continues to invest in a steady supply of personal protective equipment. Um, all associates since may have been wearing K in 95 masks throughout the community, as well as face shields where appropriate, which actually exceeds the CDC recommendations back in March Silverado contracted with a private lab to secure a dependable, accurate source for testing. Silverado has long been the clinical leader in caring for those with dementia. And even during this pandemic has achieved industry low transfer rates to the hospital and continues to exceed CDC protocols, to maintain a safe and engaging environment for our, Speaker 0 00:08:36 You know, some professionals have questioned what an appropriate referral to Silverado is during this pandemic of some professionals have shared this Silverado declined a particular referral of a resident with behaviors whom we've previously accepted. Is it simply too difficult to care for residents with behaviors during a pandemic? Speaker 1 00:08:53 I think it's important to that. It may be too difficult for someone without the protocols and, and what Silverado has in place to care for it. However, I also have to mention that early on in March at the very beginning of the pandemic, hospitals were very concerned and they were cleaning out the beds in the hospital and behavioral health was not accepting any referrals. And so at that time it did make it a little difficult to really provide the full continuum of services that Silverado would provide typically for someone with significant behaviors in a dementia that has now resolved. So that is no longer an issue. You know, our focus on the wellbeing of all residents and their situation is really unique. And having the strong clinical team that we have allows Silverado to determine what level of care is the most appropriate for them. The added restrictions that the pandemic has necessitated have made health care facilities with a more specialized level of care, more appropriate for some residents, although we still make every effort to bring our life enriching care to individuals with challenging behavior. Speaker 0 00:10:04 Well, let's review the top concerns shared by professionals and we've discussed thus far. So they've been around visitation concerns around social distancing in a memory care environment. And whether it's smaller, living options are safer. You know, we've discussed clinical protocols, including the proper utilization and access to PPE and questions around what an appropriate referral looks like. The Silverado during this pandemic, the last major concern shared by professionals was around the limitations of tele-health with the move to tele-health for many clinical and psychiatric needs of the residents. There is a concern cam that certain red flags will be missed that likely would be noticed during in-person visits. What are your thoughts? Speaker 1 00:10:45 Well, I feel strongly that Silverado's really strong clinical team, which is led by an RN with licensed nurses on site 24, seven supported by both a dedicated medical director and a master's prepared social worker, coupled with every associate in the community, regardless of function, having earned their Silverado dementia certification, all collectively act as one's eyes and ears, to notice those subtle changes in condition, which couldn't be missed by tele-health and other settings, you know, Silverado has tracked detailed clinical outcomes for over 23 years and continues to set the bar in the industry with the lowest transfer rates to hospitals because of that robust clinical model of care. So Ronald communities only serve the memory impaired since the founding of the company 23 years ago. And it's that singular focus on dementia, that results in a very highly level of training and really an expert staff that can partner with the physician nurse practitioner or other medical professional, who is on the other end of the telomeres visit. Well, I want thank you, Kim, for sharing Speaker 0 00:11:54 With us, the many reasons that professionals across the country have confidence in Silverado's reputation as the memory care expert, to meet the unique challenges of caring for residents with dementia during the COVID-19 pandemic. The fact that we've figured out how to facilitate safe in-person family visits, even in our welcome neighborhood, plus our clinical leadership in memory care that again showed our innovative culture, even during a pandemic by standardizing early on to can 95 mass and also securing a private lab for testing and segregating our communities into smaller neighborhoods, which allowed us to cohort staff where possible to reduce the risks from COVID-19. This should give you confidence and Silverado to provide real solutions. During this pandemic, I encourage you to visit our website@silverado.com to learn more about our COVID-19 protocols and safety measures, families, either struggling at home to care for their loved one during this pandemic or their loved one is isolated in a long-term care setting that simply is not able to care for their dementia, and they need our help. Please call our family ambassador at your local community today and refer us that patient client or resident who desperately needs hope, and also needs our engaging environment during these challenging times, may God bless you all. Speaker 2 00:13:16 .

Speaker 0 00:00:03 Welcome to Silverado's memory care podcast. My name is Jeff from senior vice president of communications. And joining me today is our senior vice president of clinical services. Kim Bertram, who will help us address the top concerns from families, caring for a loved one, with a memory parent disease. During this pandemic as a gerontological nurse practitioner, Kim has over 30 years of experience serving and treating those with neurodegenerative disorders. Having worked at UC San Diego's Alzheimer's disease research center and the memory center at Seton brain and spine neurology in Austin, Texas Kim oversees Silverados, university affiliations, and also leads all clinical research studies in which the company participates, you know, Kim and I both feel our responsibility as the industry leader in long-term residential memory care is to provide answers to the most common questions and concerns. Families and professionals have caring for a loved one, caring for a patient, a client, or a resident with a memory impairing disease. Speaker 0 00:01:04 Today, we will address the top concerns from families, whether to move their loved one into a Silverado memory care community. During the COVID-19 pandemic Silverado has 21 memory care communities in six States from Newport beach, California, to Alexander Virginia. And we collected feedback from families across the country who struggled with the choice to move their loved one into a Silverado community. During this pandemic, let's get into the top fears and concerns shared by families. The first and most common concern shared with Silverado is around visitation. Families ask will lock downs and safety protocols prevent me from being able to visit my loved one. And in contrast, will in-person visitation policies make a facility more vulnerable to a COVID outbreak? What are your thoughts? Kim Speaker 1 00:01:54 Visitation is an absolute priority to maintain our residents quality of life, and we've taken steps to encourage it however possible that might be by a video chat or in an in-person prearranged visit. Physical visits can be safe if we're following strict physical distancing protocols as established by local and federal authorities, as well as the infection protocols that we have put in place at Silverado, including the use of medical grade, kn 95 masks increasing ventilation in our communities scheduled hand-washing and respiratory etiquette. You know, we know that an in-person visit is the first choice for most families and residents. We're working very hard to accommodate those in-person visits whenever possible. In general, our associates are dedicated to facilitating open communication while one is in our care. And this focus has been redoubled during the pandemic to allow loved ones, to see that their family is receiving the absolute best care possible. The second most common concern Speaker 0 00:03:00 Shared by families. Kim is rooted in the emotion of guilt. You know, families will share with us. I feel like moving my loved one into a memory care facility during a pandemic is like abandoning them or giving up on them. What would you say to that? Speaker 1 00:03:16 You know, the desire to care for a loved one is a noble and loving calling, but it's really important for people to realize that it may not be the best option for you if their loved one with dementia or themselves preventing caregiver, burnout, limiting dementia, exacerbating isolation, and having access to life enriching engagement programming like our nexus at Silverado, which is an internationally recognized evidence-based brain health program, which has been validated by academic research to show that participants in nexus at Silverado showed a statistically significant 60% improvement in cognition when compared to those who had not had such treatment available. So those are just a few of the reasons that choosing the right care facility may actually be the greatest act of love that you can do for your loved one. Speaker 0 00:04:09 Oh, thank you for that, Kim, you know, the first two concerns from families were on visitation and these powerful feelings of guilt. Um, others have shared the feelings around a fear of a second wave from this virus. Uh, if a second wave of this virus hits, will the health risks increase for my loved one? Will your community go back on a lockdown? Speaker 1 00:04:32 You know, during the first wave of COVID-19, most people were really hit by what wasn't known, the name novel virus means it's a novel, no one has any experience with it. Um, no community had knowledge of what were effective treatments, what were appropriate PPE protocols or even had access at that time to testing Silverado, I can really say proudly, um, has really been the leader in innovating protocols for those living, with a memory impairing disease, to help protect memory care communities from the virus. And if an associate does become positive from outside exposure to then prevent the spread throughout the community. Some of these innovations that we are currently doing that are a part of our protocols include the utilization of can 95 medical grade mask, uh, cohorting of staff in segregated neighborhoods. And those have made a huge difference in what we have seen as we've gotten more experience with COVID, Speaker 0 00:05:35 You know, on this topic of a second wave, I think as we've seen the virus, uh, is endemic in all of the communities that we live in. What have we learned, uh, that gives us so much confidence, uh, in being able to protect those that we care for. Speaker 1 00:05:51 It's been really dramatic in terms of what we have seen once we, all of our infection control protocols in place. We now have experienced that in our memory care communities, we have had 10 different communities that at one time when we've been doing mass testing of all associates, which, which is being done periodically, where we have had an asymptomatic associate. So someone who hasn't been sick looks fine just like they can occur in the greater larger community, but who was positive. And in follow-up testing in those communities over four periods for four different periods, we had no residents become effected. That's Promatic that, that says that our appropriate infection control protocols work, use the universal masking and the other things we have in place. So, um, I think that speaks very well. And I have to say confidently that I would feel comfortable placing my loved one who needed memory care even at this time. And particularly since it seems like this pandemic will be going on for months longer. Speaker 0 00:07:02 And we're more concerned about the ongoing isolation with a resident with dementia. Well, we'll get into that a little bit more later. Well, can the next concern shared by families is related to the cost of memory care. Many have shared that I'm concerned about the uncertainties of the economy caused by the pandemic. Is this a good time to invest in long-term care for my loved one? Speaker 1 00:07:25 No time is a good time for memory care and dementia. Doesn't follow anyone's timeline. You know, I have to say the cost of care is always a factor even during the best of times and times of economic turmoil make that more uncertain. But, but it's important to understand when choosing care options, what is best for what is gained for it, your loved one's wellbeing, brain-healthy programming having the expertise of care professionals to support your loved one during this pandemic, as well as the expertise to work with our family caregivers. So those are all things that can prove significant value at this time, particularly. Speaker 0 00:08:09 Yeah, and we have to remember that even during a pandemic, we are still treating a disease and dementia does not pause during a pandemic. So families have told us that oftentimes delaying placement is delaying care. Speaker 1 00:08:22 And, and in addition to that, not just delaying care, I would say that what is sometimes put in place to deal with the pandemic can actually worsen one's dementia, not just isolation, but um, sometimes people have to use medications and, and chemically restrain someone who might not be following social distancing protocols. Those are the stories we've heard about other locations. And so having a safe, but open and secure environment like Silverado is from my perspective is absolutely the best choice. Speaker 0 00:08:57 Even during a pandemic isolation and loneliness are real issues for someone with a dementia. You know, families have experienced conditions where residents have been isolated in a room in the community, or even restrained to contain behaviors associated with being isolated. We're hearing these stories of many other long-term care environments will my loved one, be isolated in a room at a Silverado community. Speaker 1 00:09:23 Social interaction is vital to a good quality of life and an absolute irreplaceable part of our care. So of course we have taken the appropriate safety protocols to mitigate risk of those social interactions, but the social interacting and the, uh, programming continues in our communities. That is the way we give life. So, you know, experts have brought attention to social isolation as a risk factor for various physical and mental health conditions like heart disease and high blood pressure obesity, diminished immune response, which is particularly important during the pandemic, um, depression, anxiety, and even cognitive decline. Some of the evidence that we've had for our nexus programs, uh, had research that showed that a smaller social network actually had to do with how severe the dementia appeared that a resident had that a person had. So this isolation that is being caused by the pandemic is absolutely a very, very tough and can worsen the dementia. And I was struck by former surgeon general, Vivek Murthy, who said that for years of caring for patients, the most common problems he saw wasn't heart disease or diabetes. It was loneliness. Loneliness is really a concern in many long-term care environments, small residential homes, board, and care group homes, as well as senior living communities that aren't equipped to effectively provide a safe and engaging environment to dementia residents during this pandemic. Speaker 0 00:11:04 Okay. Um, let's review the top concerns from families we've discussed thus far. So we've, we've discussed questions around visitation was, was the top one that was shared, followed by feelings of guilt, um, concerns around the economy and the cost of memory care. Uh, we talked about the anguish of isolation and loneliness, and the last major concern shared with Silverado that families are wrestling with is related to the news about a potential vaccine on the horizon. Should I wait for a COVID-19 vaccine before moving my loved one into a Silverado memory care community? Speaker 1 00:11:39 Well, scientists around the globe are working tirelessly currently on a vaccine. And there are some optimistic projections that place a vaccine as early as a few months away, it could be years. And you know, when add that to what can happen in terms of progression of a dementia and how the proper care can affect quality of life, the benefits of care outweigh the uncertainty of a vaccine. It is important to consider the possibility that there won't even be an effective vaccine for really years to come. In fact, there's still no vaccine available for the 2009 H one N one pandemic, which infected over 60 million Americans and HIV is another example of a deadly virus where scientists have developed effective therapies without an available vaccine. You simply cannot wait for a vaccine to take care of your loved one living with dementia. Speaker 0 00:12:33 Yeah, well, I want to thank you, Kim, for sharing with us, the many reasons families from across the country have confidence in Silverado's reputation as the memory care expert, to meet the unique challenges of caring for their loved ones, with a dementia during the COVID-19 pandemic. You know, the fact that, uh, you and the clinical team and our operations team have figured out how to facilitate safe in-person family visits, even in our welcome neighborhood, uh, where we, uh, move in our new residents, plus our clinical leadership and memory care led by you. That again, showed our innovative culture, even during a pandemic standardizing early on to can 95 mass securing a private lab for testing and segregating our communities into smaller neighborhoods. This enabled us to cohort staff to reduce the risks from COVID-19. This should give families hope that there are real solutions available. I encourage you all to visit our website@silverado.com to learn more about our COVID-19 protocols and safety measures. Too many families are either struggling at home to care for their loved one. During this pandemic or their loved one is isolated in a long-term care setting that simply is not able to care for their dementia, and they need our help. If that describes your situation, then I encourage you to call our family ambassador at your local Silverado community today, and schedule a time to visit. May God bless you all. Speaker 2 00:14:02 .