Search for tag: "alzheimers"

Interviewer: With aging loved ones in our lives, we always kind of in the background of our mind are worried about them developing some sort of a cognitive disorder like Alzheimer's and dementia. But it gets a little tricky because general memory trouble is also a pretty common effect of aging. So the trick is how do we as loved ones recognize cognitive impairment and when it's just our loved one having a senior moment?

Dr. Michelle Sorweid is a geriatric physician and a cognitive disorder specialist with the Aging Brain Program at University of Utah Health.

Dr. Sorweid, say an older parent or loved one seems to be forgetting things. Maybe they use the wrong words for things fairly consistently, tell the same story every time I see them. Are these things that I should be worried about, or is that just part of getting older?

Dr. Sorweid: If someone came up to me and asked, "What should I be looking for in my loved one?" things that are commonly noticed are short-term memory changes, so repeating details of things that you know you've talked about before, especially if they're really important topics, but maybe not necessarily. And then there is a really common presentation where people might not recognize these changes in themselves. It's probably going to be others, like loved ones or coworkers or even acquaintances, that notice these changes.

Interviewer: Let's start with, first of all, as an onlooker, what are the different types of cognitive impairments that I should be aware of, and how do those kind of show up? Or are there too many really to talk about? Can you narrow that down for somebody?

Dr. Sorweid: There are quite a few. There are over 100 different causes of memory and thinking changes. But I would say a lot of them have many overlapping characteristics.

The one thing that I want to definitely make sure people are aware of that's less commonly known is that short-term memory isn't the only presenting symptom. Sometimes we might see things like personality changes or even severe depression or what seems like severe depression. So kind of lack of interest in their day-to-day activities, things they used to enjoy. Those can be signs that something is changing in the brain.

You mentioned word-finding difficulties, whether it's substituting words that don't make sense or describing words instead of using the word they want to use, especially things like common words. We all have "senior moments," but really those becoming more and more frequent or, like I said, using words that maybe don't quite fit.

Interviewer: Do you find that some patients kind of ignore these symptoms, first of all, as we already talked about, because it's just kind of attributed to "Oh, just getting older"? But maybe because there's a little bit of a fear of what they might find out?

Dr. Sorweid: Absolutely. I think there are a number of reasons people tend to not want to seek help. There are a lot of cultures specifically that have a stigma against people with memory and thinking changes. I know spending a lot of time with Hispanic communities throughout the world, the word "dementia" in Spanish means crazy. And so we try not to use that word specifically for certain communities.

But yes, there are a lot of reasons why people might not seek help. Again, the lack of cures for a lot of these diseases. But I think the one thing that patients and families may not realize all the time is that part of this disease process oftentimes includes lack of insight or not being aware of one's own deficits. And so that's really difficult to navigate as a family member of someone you know is having changes and they insist that they're not and that things are fine. It might be tricky getting them to even see a provider to figure out what's going on.

So we encourage our families and patients to seek this type of screening assessment or visit as maybe just seeking a baseline and finding out where things are at. That way, if there are changes down the line, we have a comparison.

Interviewer: And as a family member, if I understand correctly, a primary care physician actually has access to some screening tools. So one could accompany an older adult to an annual type physical or health checkup and request that these screenings be done if, I guess, they're having difficulty convincing the individual. Or is that the kind of trickery you wouldn't recommend?

Dr. Sorweid: No, I would really encourage family members to present to physician visits with their loved ones and provider visits. So that is something I would definitely encourage.

And then spending time with them in their own home can be really helpful and eye-opening and seeing what's going on day to day, what's going on with their medications and how they're managing them. What does their home even look like? That can be really eye-opening.

But yeah, seeking help from their primary care provider can be really helpful and asking for something like an annual wellness visit, which is covered by Medicare.

Interviewer: Back to the afraid to acknowledge it because for fear of finding out that they might have a cognitive impairment that really not a lot can be done about. I understand that a lot of causes could also be physical, that if you take care of the physical, then the cognitive issues clear up as well. Talk about some of those physical symptoms that might present that would go hand in hand with cognitive issues.

Dr. Sorweid: Absolutely. So we know that there are a lot of things that we can treat and intervene upon as far as preventing further decline or treating symptoms related to memory and thinking changes, so things like high blood pressure, diabetes, high cholesterol, abnormal heart rhythms, sleep apnea. So there are a lot of different changes that we know make an impact on memory and thinking, on the brain.

Interviewer: Do you find that patients are afraid that they're going to find out that they or their loved one have Alzheimer's? I mean, is that the inevitable outcome if you start noticing some cognitive decline?

Dr. Sorweid: Not all memory and thinking changes equate to Alzheimer's disease. Not all memory and thinking changes equate to a dementia process. That's certainly a possibility, but the earlier we know what's happening, the more we can make an impact on someone's quality of life.

There are oftentimes things we can do to really improve someone's day-to-day, such as harmful medications that either are over the counter or may have been prescribed by a provider just lacking that training with older adults. There are mood disorders that can be treated and improved. I have some patients who've come to see me that thought they were developing a dementia process and it turns out they were just severely depressed. And so we were able to help them in that respect.

Interviewer: So it's really important for loved ones or acquaintances or friends to bring this up with that individual. Do you find that the individual is pretty open then to seeking help, or not so much? And if so, how can you help them get help?

Dr. Sorweid: Yeah, not always because of what we call lack of insight, which is very common in older adults with memory and thinking changes. They may not recognize what's going on in the brain. The brain is kind of playing some tricks on them. They may not recognize what's happening in and of themselves. So they therefore might not be as likely to seek help or be amenable to someone else saying they need to.

So I think I would try to take the approach of, "This is just an assessment to see what your baseline is there, and if there are changes down the line, then we have this baseline." It's a part of just your general health, just like getting the flu vaccine or getting screened for depression or a mammogram.

Interviewer: And then if somebody does come in and they have the assessment, which you can just get at your primary care physician as they have access to these tools, and it comes back, then what would potentially be the next steps at that point?

Dr. Sorweid: So asking for that assessment from your primary care provider through the Medicare annual wellness visit, which is covered by Medicare every year, is a really good first step. And then if your primary care provider isn't as comfortable about taking next steps, for example, certain blood work or MRI or additional testing, then that would be the time that you could request a referral to us for additional workup.

Interviewer: And the sooner that you address cognitive issues, the better. Explain why that is.

Dr. Sorweid: It's really difficult to fight fires when the fires have already started. It makes it harder for us to make a large impact on families and patients when things have kind of escalated to the point where we're, again, just fighting that fire. So the earlier we know something is happening, the more impact we can make as far as quality of life, slowing decline, avoiding harmful medications, assessing sleep, and treating any sleep disorders. There's so much we can do early on.

Interviewer: And tell me a story about somebody who recognized cognitive impairment in a loved one and did something about it. How did it, in your opinion, change the course of that individual's life?

Dr. Sorweid: I do specifically remember a patient who was in the hospital for severe memory changes and also some harmful thoughts about herself. And when she was discharged, they told her she had dementia. When she came to see us, we discovered that she was actually just severely depressed. And she was actually doing really well functionally after receiving treatment for her depression. She did not have the type of dementia they suggested. She had severe depression.

So there's a lot we can do if someone has true memory and thinking changes early on. Again, I have so many examples of giving them the right diagnosis and helping families understand what's to come. There are a lot of conditions that can affect both mental and physical well-being. And so even if it's as simple as getting the patient the appropriate targeted physical therapy, or an assistive device like a walker or a cane to help them with their motor symptoms that might be related to one of these conditions, that can really make a large impact in their quality of life.

It's hard because of the stigma that goes along with these cognitive disorders. Like I said, there aren't a lot of cures for these conditions, but there's so much positive impact we can make that doesn't necessarily include medication.

Interviewer: The Aging Brain Care Program at University of Utah Health offers a range of services that help prevent, manage, and educate patients and their loved ones about memory and thinking disorders as they get older.

Dr. Michelle Sorweid is a dementia and geriatric specialist who works with the group. Dr. Sorweid, now there's a lot of different cognitive disorders. I think a lot of us laypeople just think of memory disorders, like Alzheimer's or dementia. So why don't you walk us through some of the things the Aging Brain Care Program can help with?

Dr. Sorweid: Yeah. So the most common question that I get is, "What's the difference between Alzheimer's disease and dementia?" And I try to use kind of a picture or imagery of an umbrella. So the comparison I use is actually cancer or kind of a broad term. So dementia meaning folks who've had decline in memory and thinking in one or more areas over time and that has impacted their day-to-day life, meaning they might be needing help with things like managing their medications, managing their finances, there might be errors in driving, things like that. And so Alzheimer's disease is the most common cause of dementia, and so that's why it often gets overlapped with one another. But there's quite a few other causes, as you mentioned, things like Parkinson's disease and things in that family of conditions. There may be blood vessel disease causing someone's symptoms. And there's quite the spectrum, you know, before someone reaches a dementia syndrome or qualifies for that diagnosis. There may be symptoms that are consistent with normal aging or something we call mild cognitive impairment. And so that's kind of the spectrum we look at and help diagnose and determine, you know, what's the cause and how can we intervene to prevent decline.

Interviewer: You mentioned diagnosis, which is generally, in a lot of conditions, the most important thing, is to figure out actually what's going on, and it could also be one of the most challenging things. So a specialty clinic like this, how can you make a diagnosis more efficiently, more effectively, more accurately?

Dr. Sorweid: So just like when someone comes in with a cough, we usually need more information to figure out how we can treat that cough or how we can manage it. And so it's a little trickier because we're talking about the brain. But we do a pretty thorough physical exam and history, just as with any patient coming in with specific complaints. I usually like to have a brain MRI, because that's how we take a picture of the brain. It's the most specific way to look at it. And then we usually do additional, more objective testing. So if someone, you know, comes in with a specific complaint and symptoms, we don't necessarily just rely on that. We need some objective information. So we usually do a screening assessment and then, depending on the situation, might refer them to much longer, you know, three or four hours of memory and thinking assessments.

Interviewer: And after you have the diagnosis, then you would move on to what can be done about it. And as a layperson, my perception is, a lot of times, there's not a lot that can be done about it because it's part of the aging process, and once the cognitive decline starts, I mean, there's really no stopping it. There's no cure.

Dr. Sorweid: Absolutely. It's a common misperception that having memory changes is a part of the normal aging process, and though it is common, it is not normal. And so that's one common misperception, that memory changes are not necessarily a part of the normal aging process. And then, in addition, another common misperception is that there's nothing that can be done, and unfortunately, a lot of physicians have perseverated that misconception. And so, unfortunately, we're kind of working with an uphill battle because a lot of that has pervaded throughout the medical community as well. And that's why I kind of mentioned earlier is better. There's more we can do from a standpoint of intervention the earlier we know symptoms are developing. So that includes things like managing blood vessel disease risk factors, like high blood pressure, high cholesterol, sleep apnea. There's a lot of different conditions that we know we can treat and, therefore, prevent decline or slow decline.

Interviewer: So like physical conditions that could be causing that.

Dr. Sorweid: Absolutely.

Interviewer: Oh, okay. Well, that's encouraging because that's something that, you know, one could take care of.

Dr. Sorweid: Exactly. And so that's one piece of the puzzle. But the other piece is that a lot of families and patients aren't really well prepared for some of these changes, and knowing the diagnosis really helps us help them plan for their future, know how much financial impact this might make, know what to do as far as treatment goes, because the treatment varies depending on the diagnosis. And you may have heard in the news, there actually recently was a disease-modifying drug approved in early Alzheimer's disease. So we are looking at more and more options for treatment of Alzheimer's disease specifically.

Interviewer: And at the Aging Brain Care Program, you have a lot of different individuals that can help support that family, not just physicians and neurologists but also social work support and psychiatrists as well. How do they play into helping somebody that has a cognitive disorder?

Dr. Sorweid: Absolutely. So we have a social worker who helps provide both disease education and helping manage the expectations of families and patients as far as, again, you know, what is this disease going to look like, what do I need to prepare for. So she does a great job at supporting these families and ongoing management. We also have our geriatric psychiatry nurse practitioner who is amazing. And, you know, we know that depression is a very common symptom that goes hand in hand with a dementia process or cognitive disorders. And so she's a key player in our team in helping manage these patients.

Interviewer: And what is your ultimate hope for a patient that comes into the clinic when they leave? What would be the ultimate best outcome for you?

Dr. Sorweid: I think just kind of dissuading these common misconceptions that we discussed, is that we can do something to help them, that there is hope, that they are well supported, that they don't just get a diagnosis and scooted out the door, but that they have a team on their side to help support them through this journey.

Interviewer: It seems to me, you know, the purpose of a lot of health care is to improve quality of life or maintain quality of life. How important is that to what you do, and what does that look like?

Dr. Sorweid: Absolutely, and that's kind of the common theme in geriatrics, specifically, is that quality of life is our most important goal.

Interviewer: And what does quality of life for somebody who has some sort of cognitive disorder, a memory or thinking disorder look like?

Dr. Sorweid: That's an interesting question. I think that's a very evolving question and very patient-centered, meaning that may be very different for any one individual person. That might change from year to year or month to month even, and that's something that's kind of a moving target for a lot of people. So it's something that we have an ongoing discussion with patients and families about.

Interviewer: So the Aging Brain Care Program, is it just for people who have already started noticing a decline in their cognitive abilities, or could a person come in and access your services that would benefit them before issues start to arise? Say, you know, they have a family history and they suspect that that might be an issue in the future, and they want to be proactive about it.

Dr. Sorweid: I've certainly seen patients and families who have a strong family history of dementia or who have some mild symptoms that they've noticed, and perhaps all of their screening turned out to be more of a baseline or normal, and so that is an option. I think, traditionally, that's not typically who we see in our clinic. It's mostly patients who have had some symptoms even though they may be mild. But the key thing that I would focus on with regards to a healthy aging brain is that a lot of these interventions really play a role even in midlife. So we know now that there's data that shows controlling blood pressure, even to possibly a more aggressive level, can actually help prevent mild cognitive impairment or mild memory changes.

Interviewer: When you start to recognize cognitive decline, at what point should you really consider coming into the Aging Brain Care Program? At first outset? Because, I mean, some of us can feel really weird, you know, if it's just one thing or a couple of things. How do you help a patient navigate that thought process?

Dr. Sorweid: I would really encourage at the very onset of any symptoms to seek help. Worst case scenario, you're seeking help earlier than what is needed, and, I mean, that's a good thing. Then we have a baseline. And really seeking help early, again, just kind of focusing on those interventions that we know are helpful can really make a difference in someone's quality of life, whether or not they are aware of what's to come. You know, if a loved one is complaining of, "Hey, I misplaced my keys," or "I'm forgetting names more often," there's a chance that's due to normal aging, but there's also a chance that something else is going on, especially if it's a change for them.

Interviewer: Do you recommend that somebody go to their primary care physician first, or when they start recognizing these symptoms, is it just better to come to the Aging Brain Care Program first?

Dr. Sorweid: I think if someone has a really great relationship with their primary care provider, they know them well, they're already established with someone, that is a really great place to start. There's something called the Medicare Annual Wellness Visit, and that provides all primary care physicians the opportunity every year to screen for a lot of different conditions, including cognitive disorders. And so that's something I would encourage patients to ask their provider to use as far as a tool to screen them for any problems with memory and thinking. And then, yeah, so next step or if they feel that their primary care provider doesn't feel comfortable with any of those screening assessments, then, yes, we're happy to see them.

Interviewer: And we're really fortunate to live in the Salt Lake City area and have access to University of Utah Health and the Aging Brain Care Program. How can individuals who are not in the immediate area access this great resource?

Dr. Sorweid: One of the silver linings of the COVID pandemic is having access to telehealth, and so that's one opportunity that we have to offer visits for our patients who maybe are limited by distance or who have a difficult time physically getting to the clinic. It's not ideal because there's limitations with physical exam or if they have difficulty, as many of our older adult patients do, with a video exam. But generally speaking, they're with a loved one who can help with that, so that's one opportunity. And then just to keep in mind that many of these visits aren't super frequent. It's up to the patient to how often they come to see me or one of our other providers.

Interviewer: Yeah. And a combination of perhaps those ways of visiting might work out too, I'd imagine. Maybe the initial visit is in-person because, you know, you can facilitate more of the types of physical examinations that you need to do, and then more of the follow-up visits could be virtual. Dr. Sorweid, if patients are in the Salt Lake area, where are you located, and what is the best way to reach you?

Dr. Sorweid: Located on the main University of Utah Hospital and Clinics campus, just at the corner of Mario Capecchi and Foothill, 555 Foothill Drive. And our clinic phone number is 801-581-2628. Just asking for a referral from your primary care provider would be appropriate, but we also take self-referrals.

Interviewer: If you or a loved one would like more information about the University of Utah Health Aging Brain Care Program, you can find a link to their website included in the description of this podcast.

Interviewer: It's a conversation we're not used to having or starting. I'm talking about planning for end-of-life care, and if you are planning for end-of-life care because of a diagnosis with Alzheimer's or other sort of dementia, it becomes even more complicated whether it's for yourself, or whether it's a loved one that has that diagnosis.

So to help out with that process, we're talking to Kara Dassel. She's in the Gerontology Interdisciplinary Program in the University of Utah Health College of Nursing. And her research team has developed this thing called "The LEAD Guide," which stands for Life-Planning in Early Alzheimer's and Dementia. So everybody should have an end-of-life care plan. But from what I understand, if you have Alzheimer's or some sort of dementia, that end-of-life care plan is going to look a little different. Explain why that is.

Kara: There's more of a time crunch in a broader context within Alzheimer's disease or other types of dementia where there is a limited window where you're able to engage in your family member with dementia and learn about their preferences and wishes before they get too cognitively impaired where they're no longer able to have those conversations.

Interviewer: Wow. So after the diagnosis comes in and you find out that maybe a loved one or even yourself has dementia, how soon should that conversation start?

Kara: The earlier the better. It shows that you have better care outcomes as far as having your medical decisions match your preferences if you have those discussions and document it. You're less likely to be hospitalized if you don't want to be. You're less likely to be shuttled in between nursing homes and hospitals and rehab facilities. And it's a better outcome for the people making the decisions for you because they don't have the burden of trying to guess what mom would want.

Interviewer: When it comes to advanced care planning, I thought this was interesting. I tend to always think of just medical preferences, like this is what I want medically done or not done. But it goes beyond that. And "The LEAD Guide" is based on what you call value-based decisions. Explain what that means.

Kara: Yeah. So sometimes just checking a box of whether you want a ventilator or not doesn't give you the full context of end-of-life values and preferences. And in dementia, in particular, someone may be physically very healthy but lack decision-making abilities. And so you need to make decisions about if they need long-term care, is that going to happen in the home? Is it going to happen in assisted living, a nursing home? You needed to decide where their location of death is going to be, because with dementia people live on average 8 years after diagnosis, but they can live up to 20 years. And so there's a lot of care decisions and medical decisions that need to take place within that long death trajectory.

Interviewer: So this can be a tough discussion to have. So I guess I'm thinking from the perspective of maybe a family member wanting to bring it up after that diagnosis. Are there other reasons why it's just really important to have that discussion? Again, it's not a discussion we're used to having.

Kara: Right. Not a discussion you're used to having, and I think just knowing that your window is limited puts the time pressure on having these discussions within a context of progressive dementia. And I like to frame it with families as it is beneficial for the person with dementia and the family members to have this discussion for two reasons.

One, the person with dementia has the comfort and peace knowing that they were able to communicate what they want currently and then also what they want when they have advanced dementia. That might differ. They may want something different today versus five years from now when they're in a nursing home. And so being able to communicate that can bring a lot of peace and comfort to the individual.

And then also, family members can approach it as, "Do me a favor. I want to carry out your values and preferences, but I need to have this conversation with you in order to do that." And that would relieve a lot of burden or guilt or disagreements among family members. So it's really a service to the family to have this conversation.

Interviewer: I was surprised to see in the research that you and your team did to make this guide that, for some people, the emotional burden can last months or even years, the caregiver emotional burden.

Kara: Right. If you're in a situation where you really don't know what your husband or partner wants, or mom or dad and you have to, it's an acute situation in the hospital and you have to make a decision, you may question whether you made the right decision for years. There might be a lot of lingering guilt and stress of not knowing.

Interviewer: Yeah. So I'm looking through the guide here. What I really like about it is it seems pretty simple. And this is a point where I want to say this does not replace, if I understand correctly, an advanced directive. This is not an advanced directive. This works with.

Kara: Right. This is a supplemental guide that's not legally binding, but it provides additional information about a patient's values and preferences and some of those questions that are unique to dementia, like location of long-term care and preference for location of death.

Interviewer: It starts out with a little checklist of the end-of-life documentation that you should have, which is great because that can get confusing. So I like that. And then when you start getting into some of these end-of-life value questions, I found this fascinating because I think we put ourselves in the situation by not having these conversations. Like the very first question, I'm concerned about being a financial burden to my family or close friends. For my mom, like I would spend the money to continue to make her live if that's what she wanted. But then how often is there a disconnect that that's not actually what the person wants?

Kara: Right. And so a lot of these questions here about values, they help inform decisions. So if you know that your mom is really concerned about being a financial burden, then that will help you make decisions about her care in the future. And the same with being an emotional burden or a physical burden. You know, if your mom's really concerned about burdening you physically with day-to-day care tasks, then maybe that makes you feel a little more comfortable about placing her in a 24-hour skilled-care facility when that time comes, knowing that that's your mom's value.

Interviewer: Have you seen this actually in action?

Kara: Yes. So we have . . . A part of the process of developing this guide, we held multiple focus groups with healthy adults, caregivers of people with dementia, and people with early dementia themselves. And the feedback we got was very valuable about, "Wow, this is great. I hadn't thought about this." Or, "I never knew mom cared so much about not dying at home." So it really raised a lot of questions that they hadn't discussed before.

Interviewer: Yeah, that's fantastic. Is there anything else that we need to talk about this? I think this is such a fantastic tool, especially for somebody . . . You know, I know what we need to talk about. We need to talk about somebody with dementia, not only just the deterioration after the diagnosis, but end-of-life wishes tend to be different for patients that know that they're going to have dementia versus maybe somebody that knows that they're going to have cancer.

Kara: The dementia preferences were different from those other ones as far as not wanting medical treatment interventions in a situation of dementia versus cancer. And then, having a preference not necessarily to die at home, being more comfortable dying in a nursing home or at the hospital. And so a lot of the qualitative data that we got showed that the loss of sense of self, of independence, of memory really defines quality of life. And people didn't want to extend that type of life in general.

Interviewer: Understood. My last question is this is such a great tool. Is it something that anybody could use for planning end-of-life, even if it wasn't Alzheimer's or dementia? Because I know it was specifically designed for that, but could it be used for other cases as well?

Kara: Of course. So people may lose the ability to make decisions at the end of life for a variety of reasons, due to other medical conditions, head trauma. So you can use this guide to help with any sort of advanced care planning. It's just meant to facilitate the conversation.

updated: April 29, 2022
originally published: May 13, 2020

Interviewer: It's estimated that half of scientific studies are irreproducible. They can't be replicated and this is a problem. Today, we're talking about a case study in irreproducibility, up next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. "The Science and Research Show" is on The Scope.

Interviewer: I'm talking with Dr. Heidi Hanson from the Huntsman Cancer Institute in the Department of Family and Preventive Medicine at the University of Utah. It's been estimated that up to half of scientific studies are irreproducible. They can't be replicated and this is a big problem. Dr. Hanson, you've actually published a study that feeds right into this conversation. The study calls into question a correlation that has gotten a lot of attention in the past few years.

Dr. Hanson: It's previously been reported that cancer and Alzheimer's disease have an inverse association. So basically, what's been said up to this point is that if you have cancer, you're protected from getting Alzheimer's disease later in life. If you have Alzheimer's disease, it protects you from having cancer.

Interviewer: And this got a fair bit of attention. There was a report in USA Today, there were reviews and nature of reviews, neural science and several other publications. How did the authors of those studies come to that conclusion in the first place?

Dr. Hanson: There have been a couple of studies where they've looked at individuals that have had cancer, and followed them for a period of time, and look at their Alzheimer's disease risk. And then, they also look at patients with Alzheimer's disease and look at their cancer risk later on in life. It's been published using a couple of bigger studies. They did the normal statistical methods that you might be doing just to come to that conclusion.

Interviewer: So basically, for those people who have cancer, fewer of them are found to develop Alzheimer's disease?

Dr. Hanson: Yeah, that's correct.

Interviewer: And what about that result set alarm bells off for you?

Dr. Hanson: I'm trained to think a lot about selection, and in particular, mortality selection. So what that means is I think about how processes that lead to different rates of death can affect the results that we see. And part of my demographic training is to think through some of those things. So I'm constantly looking at a result and asking if I really think that that's what's going on or if there is something underlying the result that we're seeing. So yes, it may be what the data is telling you, but is what the data is telling you actually what's going on? Are we missing something bigger?

Interviewer: Keeping that in mind, what was it that you found in your study?

Dr. Hanson: Our study replicated some of the previously reported results. And then, we showed, once you start to think about these things, and think about how mortality is affecting the rates of Alzheimer's diagnosis in these patients, you actually see a different story. It's not that there is not that inverse association that exists, but it's that mortality is driving that inverse association. It's not because there is some underlying cellular genetic mechanism underpinning both diseases. It's because if you have cancer, you have higher mortality. You're not going to go on to live long enough to be diagnosed with Alzheimer's disease.

Interviewer: It certainly makes sense. And that's actually really important, you've said, when you're thinking about aging-related disease and the aging population. Can you talk about that a little bit more?

Dr. Hanson: Yeah, absolutely. So when we're aging, there's a lot going on. You aren't usually suffering from a single chronic disease. There are multiple thing going on at the same time. And if you think of aging in a single context or aging with a single disease and you're ignoring all of those other things that are going on, you're missing the bigger story.

Interviewer: Do you think someone could come along a few years from now and find that maybe you didn't consider something in your analysis?

Dr. Hanson: Absolutely, and that's why I like science so much. We're not coming up with the best answers all of the time. It's an iterative process. We should all be considering each other's work, and we should all be critical of each other's work and figuring out how we can really understand what's going on. And to do that, it's necessary to be critical and to try to decide, okay maybe if we look at this a different way, we will be seeing something else. So maybe there is this underlying mechanism and if we're able to look at it this way, we can get more into what's going on. And that's what should be happening.

Interviewer: Yeah, that's a really good point. I think one of the issues that you had brought up is that you're really trained to really look at the data and consider all the factors that might go into some of these correlations or some of these results. What do you think can happen to make sure that some of these people who are trained in the life sciences might consider some of these other types of analysis or other types of questions?

Dr. Hanson: Yeah, one of the biggest things that I think can really help that is working interdisciplinary. If we are working across our own disciplines, naturally we are trained to think different ways, naturally we're going to approach problems from a different direction, and naturally we want to start to question different things. Things where I've been trained to somewhat ignore them through my training, someone else may look at the same problem and say, "Wait a second. You're not thinking about this. You need to be really critical of this."

And that's what's so fascinating and fun to work with individuals from different disciplines. It's how really good science is done, in my opinion. And really good science can't be done without that difference of thought. I think it's absolutely necessary. And I'm seeing a lot more of it, which is exciting.

Interviewer: So do you think this is a common problem that people aren't considering their questions carefully enough?

Dr. Hanson: I do. I think it's a very common problem. I think that people find the results that they're looking for a lot of times, and I think that's unfortunate. And I think that publication bias leads into the kinds of problems that we are seeing where people are only reporting certain things or things are only getting published if they are of interest to the public. I think that causes problems. I also think the really big push to publish fast causes huge problems. And it's unfortunate.

People just aren't as thorough with their statistics, with their methods, with their thinking through the problem as they should be because there's such a push to get the publication out. It's this huge push. Everybody wants to move things quickly, do one analysis and send it off. And that's what you do. And I think it's unfortunate.

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Interviewer: Springtime's coming up. What does that mean if you are a caregiver for somebody with Alzheimer's? We're going to talk about that next on The Scope.

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Norman Foster is the director of the Center for Alzheimer's Care Imaging and Research at the University of Utah. With the change of seasons kind of comes changes of risks and opportunities for people that are caregivers for individuals of Alzheimer's. Let's talk about that a little bit. What are some of the opportunities that come with spring?

Dr. Norman Foster: Well, we have some consistent goals for people who have Alzheimer's disease. They need to be physically active, socially engaged, and mentally alert. And so the question is how that works in springtime and there are a lot of opportunities as you mention. There's a time where people can go gardening, they can keep physically active and so let's think about changes in activities that will meet that goal of keeping socially engaged and physically active.
For example, this is a great time to get out in nature, appreciate birds, flowers, all of those things. Let's enjoy life. We're really seeking and expect now that people throughout the course of Alzheimer's disease should expect a high quality of life and getting out and enjoying the spring, the outdoors is certainly part of that.

Interviewer: That's about as good as it gets right there. Springtime. Are there any things that you should be careful of or aware of with spring coming around?

Dr. Norman Foster: Well, again, these are general principles we can apply anytime of the year but when you're out and walking around and seeing nature you want to make sure that someone doesn't get lost. And so there are a number of ways to do this. There is the Safe Return Program through the Alzheimer's Association or medic alert bracelets so that people who get separated from loved ones can find their way back. There are some very interesting, innovative GPS programs, a variety of them so that caregivers can track someone. You know, it's great to be out in the neighborhood, talk to neighbors, and to have a caregiver who's not worried all the time but can check on where their loved one is.

Interviewer: Yeah, yeah.

Dr. Norman Foster: That's important. And, of course, not taking risks. So one of the great things to do, it may be that someone who has Alzheimer's disease is no longer able to drive and has had to retire from driving but they may be able to bicycle for example. Great thing to do...

Interviewer: Sure.

Dr. Norman Foster: ...in the spring. And getting out and seeing the neighbors. You know, neighbors are more likely to be sitting on the porch or out doing gardening and so going by and visiting them, even making that a regular visit. Having a pet and taking the dog for a walk helps to incorporate that regular sustained exercise of more than 20 minutes that every patient with memory problems needs to engage in.

Interviewer: It just dawned on me spring is almost the perfect time because you think about spring, everybody's so excited to get outside so there tends to be a lot more people. And then when the summer starts coming and it gets hotter and hotter then people start going back inside again, so it's kind of like this narrow window of opportunity really.

Dr. Norman Foster: That's true and what I would emphasize is taking this opportunity because there is so much possibility to set up a regular schedule of activities. This is the time to set up those habits that we want to see all year.

Interviewer: Gotcha. Sure

Dr. Norman Foster: So patients often come to me and every patient we recommend gets regular physical exercise, 20 minutes to 30 minutes of sustained activity, walking one mile a day for example. And they'll come and say, "Well, Doc, it's been too cold or there's too much snow so I haven't been active." And then I see them six months later and then it's too hot.

Interviewer: Yeah.

Dr. Norman Foster: And so I tell them there's no excuse. This is the goal anytime.

Interviewer: Yeah.

Dr. Norman Foster: But if you set this up and think about how this can be done during the year it's just setting up that schedule, that expectation. And springtime, maybe fall, easier than somewhere in the middle of winter.

Interviewer: Yeah.

Dr. Norman Foster: But once you get that habit, gee, it's great to look for a shopping mall or a senior center where you can get that exercise when the weather's bad. You know we're fortunate here in Utah because the weather's so great much of the summer but I bet if I were in another part of the country that the explanation would be, "Well, it was raining," or there's always something that we let ourselves off the hook.

Interviewer: Yeah. Get in that habit. Maybe even have friends over on the patio and then that continues through the fall and then take it inside on the wintertime. That's a great idea.

Dr. Norman Foster: Time for turning over a new leaf.

Interviewer: Yeah, so to speak.

Dr. Norman Foster: That's right. So this is the time to set up good habits.

Interviewer: Good idea.

Dr. Norman Foster: And a time when we can all feel optimistic.

Interviewer: Any final thoughts? Springtime?

Dr. Norman Foster: Well, I think that making sure that you're out and keeping enough fluids. A big problem is that people who have memory problems may forget to drink enough and tend to get dehydrated and so having someone along, a friend, family member along to encourage keeping hydrated is important and making things interesting, you know. It's great if you go around just the neighborhood every day. Same place but let's try to make things a little more interesting too and vary habits. That's something with a good friend this is a time to renew those friendships.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope; the University of Utah Health Sciences Radio.

Interviewer: Alzheimer's 101. What is it? What's happening in the brain? What are some of the symptoms? What can be done, and what's on the horizon for potential cures. We're with Dr. Norman Foster, Director of the Center for Alzheimer Care, Imaging, and Research at the University of Utah.

First of all, let's talk about what is Alzheimer's? What are the characteristics of Alzheimer's, and what's actually happening in the brain? I find that kind of interesting.

Dr. Foster: Alzheimer's disease is a progressive disease of the brain that causes loss of nerve cells, and as a result patients first develop difficulty with memory. But then increasingly over time have difficulty with other areas of thinking and then eventually difficulty with daily activities so that they become dependent on others.

Interviewer: When you say nerve cells, is it brains cells?

Dr. Foster: These are brain cells. Yes, that's right.

Interviewer: These are brain cells. And what exactly is happening in the brain? I've heard it described as plaque of the brain. Is that accurate or not?

Dr. Foster: Well, Alzheimer's disease is caused by an abnormal accumulation of two proteins that normally occur in the brain, but in this disease abnormally aggregate into plaques and into tangles. And we now understand a lot of the basic biology of these uncontrolled protein accumulations. But we don't understand what sets this process off.

Interviewer: So these proteins start accumulating in the brain. Do they actually adhere to brain cells?

Dr. Foster: Not directly. They adhere to each other. So they begin with small fragments of protein, and then they aggregate into clumps. And then eventually form these plaques, or in the case of the tau protein, which makes the neurofibrillary tangle. These fibrils actually kind of have a spun or twisting appearance and interfere with normal nerve function.

Interviewer: It's kind of gumming up the works.

Dr. Foster: That's right. This is a disease that as far as we know just involves the brain.

Interviewer: So you spoke earlier about the symptoms. What are some things that if I'm a relative of somebody that I believe might be getting Alzheimer's I would want to be looking about for?

Dr. Foster: Well, the characteristic feature that late in life, on average in the mid-70s, people begin to have difficulty with memory. And, of course, we all have memory complaints.

Interviewer: Yeah.

Dr. Foster: And our memories are not perfect. We don't work like computers, but in these cases it interferes with a person's ability to do daily activities that they've been used to carrying out independently.

Interviewer: So, for example, perhaps they forget where they are when they're driving someplace where they've driven to numerous times.

Dr. Foster: That's possible. This is why medical attention, medical advice is so important because there's some things that are obvious, but we think it's very important to pick these up when things are not so obvious. And so there may need to be medical judgment.

One of the examples that I would use having trouble remembering exactly where I parked in a large shopping mall. That's normal, but after four or five hours not being able to figure out where it is or how to get help, that's abnormal.

Interviewer: Or how to get help. That's an interesting addition as well. When speaking of Alzheimer's, what can be done if you go and you talk to a physician to help you find some of those non-subtle things, your family member has been diagnosed with Alzheimer's, what then?

Dr. Foster: Well, I think the first important step is to know what is going on. It's quite a step. In fact, there's quite a bit of effort to evaluate what the cause of memory problems and cognitive problems are.

Interviewer: It could be something other than Alzheimer's.

Dr. Foster: It could be something other than Alzheimer's. It could be Alzheimer's with something else. For example, sleeping medications are common. Even over the counter sleeping medications can make Alzheimer's disease significantly worse, or it can cause symptoms that mimic Alzheimer's disease.

So first, making sure you know what you're dealing with is important. And then that, of course, will lead to what should be done about it.

Interviewer: Okay.

Dr. Foster: So there are many things that can be done about Alzheimer's disease where medications that are approved by the Food and Drug Administration that we know have benefits. Unfortunately, they're only modest right now, so we're looking for much more effective drug treatments.

Interviewer: Does that slow down the onset of Alzheimer's'? Does it get some memory back? What do these drugs do?

Dr. Foster: Well, the medications that have currently been approved by the F.D.A. compensate for chemical losses that occur in the brain typically in Alzheimer's disease. So many of them are very specific for Alzheimer's disease, and don't affect or improve all kinds of memory and thinking problems. But this is actually the kind of chemical byproducts of the plaques and tangles rather than getting at the plaques and tangles themselves.

Interviewer: What do those chemical byproducts do?

Dr. Foster: Our nerve brain cells talk to each other by what are called synapses. So there's a chemical that's released at the end of one nerve that is then picked up by another nerve. And so when nerves are sick, they have difficulty synthesizing, creating this chemical message system, and that's what these drugs do is try to compensate for that, restore some of the chemical changes that are lost in Alzheimer's.

Interviewer: What else can be done? So you've got some medications. What are some other options?

Dr. Foster: Right. So right now one of the important things to do is help the patient. The patient needs to have help with day-to-day activities or doing things. For, example, if it's only memory problems, then one of the things you need to do is write down things so that you can read and to see what you remember.

We can no longer do or depend upon some things that we took for granted before. So, for example, you're in the doctor's office. The doctor says, "Come back and see me in two weeks," and they give you a date. And then after the doctor leaves the office if they haven't written it down, you don't remember that day.

Interviewer: Yeah.

Dr. Foster: Now, maybe that could happen with any of us, and it's always a good idea to write those down or keep a calendar. But if you know that you have Alzheimer's disease or a memory problem, that's something that you really have to pay a lot of attention to. But there are other things that are very predictable. Complications, I call them, of Alzheimer's disease that need to be addressed.
Other Effects of Alzheimer's

For example, people who have memory problems get embarrassed by this, and so we often see that patients and often other family members become socially isolated. That's exactly opposite of what people with this disease need. They need to be interacting with others, have a good quality of life. And not leaving your house, and sometimes the wife or husband not leaving the house also, that's bad.

Another example is social activities. You may be embarrassed because of memory problems and withdraw from your friends at the very time that there's most important to you. And then also there can be problems with family. A family doesn't understand what's going on. They misunderstand and, therefore, act on assumptions that they make that are in error, particularly if they haven't sought medical advice to understand what's going on.

So one daughter might think, "Well, he's just trying to get back at me. That's why he's not doing things." Or "I think he's just depressed so we should try to make him happy." Or that this is related to medication. There are all sorts of possible explanations, but the family members are pulled apart by disagreements and conflicts, not being on the same page about how to support their loved one. Then we often see disasters, complications not just socially but within families because of this disease.

Interviewer: It appears as though the Alzheimer's affects the brain. Does it otherwise affect you physically directly, or is it the indirect effects? You're embarrassed. You don't leave the house. So now you're not getting any exercise. You're not getting any social interaction. Is that where a lot more of the danger is?

Dr. Foster: Well, I often get asked questions about whether Alzheimer's disease kills? And we know the people who have Alzheimer's disease at every point in their illness are at greater risk of death. Now, this doesn't just happen because of the plaques and tangles, but because we depend on our brain for many things.

Interviewer: Yeah.

Dr. Foster: You just described some of them. Our motivation, for example, get up and go, all of that sort of thing makes a big difference in our physical health. We know that people should be active, but also it affects our ability to seek help. For example, if you have chest pain and you're not able to seek help, then you're going to die from a heart attack more likely than somebody who does seek help.

If you forget the medication that you need to take for diabetes, then you're going to have complications of diabetes and die from that earlier. Our brain also-in ways that we don't as much understand-are involved with basic daily function and maintaining our physical health. So that people who have brain injuries, whether it's due to trauma or other things die earlier than people who have good functioning brains.

Interviewer: Let's talk about some potential cures or things on the horizon that excite you. I know that you keep very in touch with the research that's going on in the United States and the world. Is there hope on the horizon?

Dr. Foster: There is hope. We know much more about Alzheimer's disease. And I think one of the important things to recognize is that Alzheimer's isn't simple. It's a complicated disease. There are two proteins that accumulate. They affect the brain in complex ways. They change the chemistry of the brain.

So I think that it's unrealistic to expect that we're going to find a single drug or penicillin that's going to cure the disease. It's much more similar to cancer. We're going to make gradual, progressive improvements step-by-step, identifying how this disease develops and stopping it in its tracks.

And, of course, a lot of our efforts now are in trying to develop treatments that we would give early in the disease before there's so much damage to the brain. So we think that it's much more difficult after there is so much damage to the brain of correcting the problem. So early identification, early treatment is the way we're going, and there are many exciting possibilities.

We know that these two proteins that accumulate in the brain do so when they get slightly off balance earlier in life. So these slight differences or the slight imbalance over a period of years becomes devastating to the brain. And if we can offset even in a little way this imbalance, then we'll be a long way to brain health.

In addition, we know that the brain is not static. The brain can change. The brain, we call this plastic. It responds to differences in the environment, and there's good evidence now that some older individuals have resistant brains to these effect. And the resiliency is one of the things that we're trying to capitalize on, understand why some patients are so devastated by the same changes that can have less effect in others.

It's time for us to give the best care to patients with Alzheimer's disease. They deserve the dignity and dignity of care.

updated: December 2, 2020
originally published: September 25, 2013