/
RSS Feed
What factors throughout the life course may help reduce risk of dementia? How does precision medicine apply to the field of brain health and dementia research? What resources and interventions can promote brain health or help people live well with dementia?
Neuropsychologist Dr. Kristoffer Rhoads of the University of Washington School of Medicine. Discusses these key topics and more.
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.
