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Shaun Toomey (Inspir Embassy Row): Good. Alright, well, welcome, everybody. For those of you that know me, my name is Shaun Toomey, I'm the Director of Strategic Partnerships here at Inspir Embassy Row.
Welcome to those who have never been here before, for the first time. Inspir Embassy Row is a licensed assisted living and memory care community. Just a little bit about the community. Obviously, an elegant, beautiful building, and a gorgeous, city, urban setting. We have 174 apartments. 45 of which are licensed for memory care. So those are secure and safe, they have a different level of staffing and a different level of programming, and adaptive programming products.
So, what we're trying to do is… what we've tried to do since we opened 6 months ago, is to open our doors to our neighbors in the community, and to become a hub of information and education, a place where you can come and get inspiring lectures on all… a myriad of different topics, including, health-related topics, and this is a really critical and really topical topic today. We're going to talk about brain health. So we have… two leaders here from Sunday Health. Sunday Health is a modern cognitive care practice.
We have with us… the CEO of Sunday Health, Maria Thomas, and, Maria is really driving the innovation of Sunday Health. She's working to make, more accessible You know, early detection, being proactive about supporting folks with, brain issues. And, it's really, trying to make a change in opening the accessibility to it. It takes 6 to 9 months to make an appointment with a neurologist these days, I've heard, and something else is working to change that. So it's a really innovative thing these days.
In addition to that, they've partnered with experts in the field to, expose their patients to, cutting-edge treatments, as well as… So, we're really thrilled to have the remainder of us. Joining her is Dr. Amy Sanders, and Dr. Sanders is a dementia neurologist. She's got over 15 years' experience in clinical and academic settings. She's, led Alzheimer's research and, been published extensively. And my understanding, I haven't seen this talk, is that she's able to take these complex neurological topics and issues and make them much more manageable for… us.
So… I don't know what this introduction I thought about. driving innovation and expertise, and I think we're in for a real treat today. So, without further ado… Maria Thomas? Action. Thank you.
Maria Thomas: Good afternoon, everyone. Thank you so much for joining us. Let me welcome you, and please, thank, Shaun and Inspir for hosting us at this amazingly beautiful building, and I've had the opportunity in the past to tour, and to see, the residences, it's really just an incredible, community, and wonderful resource to be able what a host event site is to help educate and share, what people like, experts like Dr. Sanders know.
Opening Questions About Preventive Health
Maria Thomas: So, to get started, I have a few questions from all of you. How many people, if you're 50 years old or older like I am, how many people knew when you turned 50 that you're supposed to go get a colonoscopy? Yes. Most people know that.
How many of you go to the dentist at least once a year? Yay! Oral health, wonderful. Women, question for all of you. Who gets a regular mammogram, or has in the past gotten a regular mammogram? Men, same question. PSA, yeah, prostate exam. Some of you, okay, maybe, maybe we can do some work on that.
Okay, next question. How many of you have got your brain health checked? Regular annual brain health check. Oh, good group here! Love it! Love it!
Okay, well, that is a little exercise designed to help open up the dialogue of what we're really all about at Sunday Health.
Sunday Health Overview
Maria Thomas: So, as Shaun mentioned, my name is Maria Thomas. I live right here in D.C. I am the CEO, but not a clinician. I am the CEO of a group called Sunday Health. We are a specialized care practice focused exclusively on cognitive care.
Cognitive care, that means memory and thinking. And we are right now operating in DC, Maryland, and Virginia. We are a relatively new, but not brand new organization. We've been around for about 2 years.
And, one of our big ideas here is to elevate the idea of proactive brain health. So the reason I asked you all those questions is that somehow, in the United States, we've kind of gotten our heads around the idea of preventative health, or, you know, screenings for cancer, or, you know, our oral health, or whatever it may be, we all understand that there are certain things we could do to stay healthy in different areas of our body.
We need to remember that for our brain. And so, here at Sunday Health, we're really trying to elevate the idea of proactive cognitive care. Now, here's talking a lot about that today. So, the way we're gonna do this is, I'm gonna give a little bit more introduction to Dr. Sanders.
She and I are gonna have a dialogue about, some basic… make sure we have level setting, get into some of the new things that are happening in this arena. When I say this arena, I mean how we care, dementia care. We're gonna talk about some of the new blood tests, some of the new drug-based therapies, and very importantly, about non-pharmacological interventions.
And then we'll open it up for questions from all of you and from our online audience. How's that sound?
Okay. Well, I like when I see body nods, and I know you're awake. Stay with me, everybody. Dr. Sanders is a real expert, as Shaun said, in, dementia neurology. She's been practicing since 2008. She had a medical degree from Albert Einstein College in the Bronx. Where she was also, a tenured professor. She's also had a professorship at Upstate University of New York. And most recently, before joining us at Sunday Health, was a founding clinician and leader at the Ayer Neuroscience Institute at Hartford Health in Hartford, Connecticut. And Dr. Sanders does live in Connecticut. Because at Sunday Health, we provide, care both in person. And we did talk about, and we'll talk more about that and how that works, if you're curious about that. So, welcome, and hello, Dr. Sanders.
Defining Dementia vs. Alzheimer's Disease
Dr. Sanders: Hello, Maria, and… can people hear me? All the way in the back? I have a really loud voice, so I'm just… Do you want me to use the mic? Okay, alright, thank you.
Testing.
Okay, great, well, hello, hello! Yes, nice to be here with you. So we like to start, usually with some kind of definitions, if you will, just to make sure that everyone's operating with the same language. And then we can communicate, which is useful. So, Dr. Sanders.
Maria Thomas: Yes, Maria? What is the difference between dementia and Alzheimer's disease?
Dr. Sanders: Before I answer that question, and I love to answer that question, I'd like to see a show of hands. How many people believe that you know the answer to this question? How many people believe you know the answer to the question? What is the difference between Alzheimer's disease and dementia? Okay, I'm now going to tell you what I believe is the difference, and then I'm going to want to see a show of hands again. Be honest.
Were you right at the beginning? Because, why am I setting it up this way? You would be surprised, or maybe you wouldn't be surprised. At the number of people who do not understand that these are not interchangeable terms, they are very much related terms.
Dementia. The word. Dementia. is nothing more than a catch-all term, if you will, an umbrella designation for the situation where somebody has cognitive impairment. That has become significant enough. It is now beginning to impair a person's ability to live their lives in their usual way. Maybe they get lost when they're driving in familiar places, and so they no longer can drive a car. Maybe they no longer can manage their own money, or manage their own medications.
Or, perhaps they no longer are safe to use the kitchen. There are all sorts of different ways that function can decline as a consequence of impaired thinking. And that is all dementia means.
Dementia is nothing more than impaired thinking that is causing an impaired ability to function in one's daily life in the usual way.
Alzheimer's disease is the big granddaddy of the diseases, or grandmommy. I don't want to be, you know, gender-biased.
Alzheimer's disease probably accounts for some 60-70% worldwide of cases of dementia. Dementia is a syndrome. It's just a collection of symptoms. I told you what the two symptoms are. Cognitive decline, functional decline. That's all dementia is.
Whenever I tell somebody? I think you might meet criteria for dementia, because your thinking has declined, and so too has your function. The next sentence out of my mouth had better be, why do I think they have this dementia? What disease is causing the dementia?
Alzheimer's disease, 60-70% worldwide of the cases of dementia. I think of 3 other… conditions as sort of rounding out, if you will, the big four. There's dementia with Lewy bodies, which Robin Williams famously had. There is vascular cognitive impairment, or vascular dementia. The only… neurodegenerative. Only dementia is not neurodegenerative.
You get it as a consequence of having strokes, but if you can prevent yourself from having another stroke. We… you may be able to retard any further cognitive decline. And then, frontotemporal degenerations, which is a handful of multiple different conditions. Bruce Willis famously has one of those. So those are the big four dementing diseases. Dementia, just a catch-all term that describes the state where cognition has begun to fail to, the degree that it is now impacting that person's ability to take care of themselves fully.
And? And? How many of you got it right?
Most of you did. Very good. Yes, for sure. But we have a question that we'll go ahead and take, please.
Clarifying Dementia vs. Alzheimer's
Maria Thomas: I think, just to repeat the question for people online, the question is, I'm gonna paraphrase a little bit. The question, I think, is still a little bit about the difference between dementia and Alzheimer's. Or is Alzheimer's dementia, is that what you're asking? I think what Dr. Sanders was just saying is that Alzheimer's is a disease, is a dementing disease. So, if you think of, you know, dementia as the umbrella term, Alzheimer's is a disease that, is under that umbrella. It is the largest 60-70% of the dementia diseases. So, yes, is the short answer. It's not the other way around, because I always thought…
Dr. Sanders: So, it helps, I think, sometimes to reason by way of analogy to cancer. Cancer is also a syndrome. It's a syndrome caused by some… cluster of cells somewhere in the body, proliferating way more than they should.
So if you hear that your next-door neighbor has cancer, typically, what's going to be the next question out of your mouth? What kind? Exactly right. Same reasoning should apply when dementia comes up. If you hear that your next-door neighbor has dementia, the next words out of your mouth should be, what kind?
And so then you want to know, is it Alzheimer's disease? Is it vascular dementia? Is it dementia with Lewy bodies? One place where it does occur to me that, sort of… confusion lies in the nomenclature itself, is that sometimes people call Alzheimer's disease Alzheimer's disease, sometimes they call it AD, which is the initialism for Alzheimer's disease, and sometimes they call it… they use a term called AD dementia.
And that's usually, when somebody wants to… distinguish between a clinical state of dementia cognitive decline, functional decline, due to Alzheimer's disease. be able to distinguish that from earlier stages of Alzheimer's disease, because also what we know is Alzheimer's is not a… binary, all-or-none phenomenon. It is… Increasingly now, too, we understand this to be a continuum of disease.
It goes everywhere from preclinical disease, which means that you have something that maybe becomes a blood test, but you have no symptoms. To symptoms involving cognition, but not function. and then symptoms involving both cognition and function. So the terminology itself can be somewhat unhelpful here. So let's just extend that one more, one more… into one more area. Dr. Sanders, you mentioned the continuum. What's… what's mild cognitive impairment, or MCI?
Understanding Mild Cognitive Impairment (MCI)
Dr. Sanders: MCI is itself a diagnosis. There are diagnostic codes that I can enter into somebody's chart for mild cognitive impairment. Please hear capital M, capital C, capital I, when we use it in that phrase, MCI, we are defining a disease entity. If we have a lowercase m, c, and i, then we're really sort of using it in a descriptive way.
Always, mild cognitive impairment lies somewhere between normal cognition for age. And cognition changes as we age, so a 35-year-old's cognition is going to be… measurably different from 75-year-olds' cognition. So if you say that somebody is normal for age, we are saying that about a 75-year-old who is similar to other 75-year-olds. Not necessarily similar to 35-year-olds, that probably wouldn't be a fair comparison.
But, similar to other 75-year-olds, you're good to go. And then, if somebody has at least one area of thinking where there is objective evidence of impairment. That means you have been formally tested. Most people don't realize that.
Many physicians don't realize that, but you need to have some sort of formal testing that demonstrates an objective impairment in at least one type of thinking.
If you just come to… the doctor's office and say, gosh, you know, I really am worried about my memory. That is not an objective impairment, that is a subjective impairment. You are subjectively saying, doc, I think that my memory is shot.
If I test your memory, and I find that there is a memory problem, then there's also an objective impairment. MCI requires an objective impairment in at least one type of thinking, but no functional decline.
Does that mean that you have to do everything with the same skill and alacrity that you did with things when you were 20? No, not necessarily. We recognize that, you know. As a person ages, their ability to do some things gets better, and to do other things may take them a little bit longer to do things than I used to.
The trick is, always get there in the end. might take longer to learn a new task or a new skill. You can learn at the end, you're probably functionally intact, and that's okay for MCI, not okay for dementia.
Cognitive Decline and Normal Aging
Maria Thomas: So, Dr. Sanders, are you saying that, should the group understand that cognitive decline is or is not part of normal aging?
Dr. Sanders: Yes.
So… The way that we think changes as we age. I, I, just, mentioned one way in which that happens. It takes us longer to learn things. We can still learn them, it just might take us longer.
So, the example I used to give was, can you program your own VHS? So I'm showing my age there, right? When was the last time anybody in this room had to program a VHS? So, once upon a time, you know, that was, that was a big challenge. I know, when you have to get a new smartphone, how long does it take you to convert?
That is a non-trivial undertaking. Do not, for one second think that it is easy. I once attended a talk where somebody threw a slide up, a very, very famous dementia researcher. Put a slide up, with, you know, that basically said, this is not your mother's, your grandmother's Medicare. I just wanted, you know, to underscore, at that time, this is 20 years ago, how many changes were occurring, and that's happening in dementia medicine now.
Sorry, that might have been a tangent. So, as we get older, our brain does change in the way that it functions.
Famously, anybody in here ever not be able to find the word they want in the moment that they want it? The name of that book, that restaurant that we went to, that actor's name, even just the verb. So…
If that happens to you, and whatever was lost. is found, comes to you in seconds, minutes, hours, days, or once very memorably for me, 6 months later, that we call the tip of the tongue phenomenon.
In the vast majority of cases, that is not pathological. It is normal for cognitive aging. This is not to suggest that it is not irritating and aggravating, because it is absolutely both of those things, but it should not make you think, oh, oh, oh, is this the beginning and the end? Almost certainly, it is not.
And if you then just sort of let your brain relax. Put it on the back burner, figuratively. It may find that seconds minutes hours. days, 6 months, it does pop back into your head. So, that's the tip of the tongue phenomenon. There are many other examples that I can give you of things that are normal for the aging brain. What is never normal for the aging brain?
memory loss.
If we were having this conversation 30, 35 years ago, I would probably be describing to you a… something that we might even use the word senility to describe. That memory loss was an expected and normal feature of cognitive aging. We know better now.
It ain't that.
Memory loss is never normal. So if you are having memory loss, if someone you care about is having memory loss, please do urge them to get evaluated. It's very important, and there is a lot we can do to help them.
Cognitive Assessment and When to Get Tested
Maria Thomas: So, when we talk about getting evaluated, what does that even mean? What are we talking about? We've mentioned testing here. I know a number of you raised your hand when I asked you about, have you had your brain checked? I assume you have been, that's been part of your annual wellness visit. But, maybe we could elaborate a little bit on what we're talking about when we speak about an evaluation. Well, first of all, what are the tests that we're talking about, and when should someone be tested?
Dr. Sanders: So… Oh, am I there? Yep.
I like to say that, The best time to start thinking about your brain, and paying attention to it on a regular basis. Probably when you're in your mid-30s. I'm gonna go out on a limb and guess that that's probably a lot younger than a lot of you expected. Why do I say that? Well, it takes probably at least until the mid-20s, probably a little bit later than that, for the brain to achieve full physical maturity.
This is why, when people are still teenagers, or maybe in their early 20s, they perhaps don't make the best life decisions. The brain is not yet fully mature, physically. By the time that we're in our mid-late 20s or early 30s, it is fully physically mature. And then I'm going to tack on…
3-5 years for life experience, but by the time one reaches one's early 30s. Might become the foundation for later life wisdom, or so we hope.
Once we are 35, things do begin to change, and this process of cognitive aging begins. And so that is probably the best time to start paying attention.
Absolutely. If you have grandchildren, suggest that they start doing it even earlier than 35. It is… there's no way to start paying attention to your brain too early.
It's also true. It is never too late to start paying attention to the brain.
So… Preclinical disease, mild cognitive impairment, mild stages of any kind of dementia, moderate stages of any kind of dementia. There are things that a practice… a physician like me, and a practice like Sunday Health can do to help.
Many people often think, I don't want to go to the doctor, I don't want to find out, because nothing can be done.
Nothing could be further from the truth.
And if you leave here today taking only one take-home message home to treasure with you for the rest of your days, let it be that one.
There is always a way that we can help.
New Developments in Cognitive Care
Maria Thomas: Thank you for that, Dr. Sanders. So, one of the reasons why we formed Sunday Health is that there's a lot happening in the arena of cognitive care right now. And when I say a lot, some of you may have heard of some of these things, but we have new, blood tests that can be used for diagnostic purposes. We're going to talk a little bit about them.
There, in the last just 3 years or so, have been 2 new FDA-approved, disease-modifying drug therapies. So these are disease-modifying, not… not drugs that just address the symptoms.
And there has been a mountain of research, including most recently, just at the Alzheimer's International… Alzheimer's Association International Conference last month, a new study out called the POINTER Study, with this mountain of research, including the POINTER Study. really grounds us in the importance of lifestyle factors and their impact on our brain health. When I say lifestyle factors, I mean things like, what you eat, whether you are getting… whether you're wearing your hearing aids if you need them.
whether you're socializing, there are many of these factors, we call them modifiable risk factors. So when Dr. Sanders says, it's never too early and it's never too late. There are things that we can do, and that we at Sunday Health embrace, and we're gonna talk about those things now.
So let's start with these modifiable risk factors. There's a lot of research in this area. If you're the kind of person who enjoys reading the research, you can refer to the POINTER study, just like it sounds, POINTER study. A year ago, there was a study called… out from the Lancet Commission. LANCET, which specifies these modifiable risk factors, so this is not Sunday Health. We incorporate this into our care model, but this is a scientifically grounded, validated research that we're incorporating. So, turning back to you, Dr. Sanders.
So when we talk about these modifiable risk factors, maybe we could start with what's modifiable and what's not modifiable.
Modifiable vs. Non-Modifiable Risk Factors
Dr. Sanders: So… What's not modifiable? That's pretty, that's pretty easy. Things you cannot change. So, who your parents were. Which is another way of saying what your genetic makeup is.
Many of these diseases have some genetic dimension to their natural history, but are not exclusively genetic diseases.
And that varies by dementing disease, but, so, you cannot change… your genetics. Now, if there were geneticists, any geneticists still…
Okay, good. So I had a need to talk about the phenomenon of epigenetics, which suggests that, in fact, you can change your genetics, but not in the way that you're thinking. So, you cannot get in the Wayback Machine, or a time machine, and go back and change where you went to school, how well you did in school, and, who you went to school with.
You cannot change… I saw a brow furrow. Why do we care? Why does education matter? Education is recognized as being a protective factor.
So, I… went to college, then I went to graduate school and got a master's degree, and then I went to more graduate school and got another master's degree, and THEN I went to medical school. I was a late bloomer. So, I did a lot of going to school. And that probably… serves me well now.
I use my brain every day when I go to work. I'm fortunate to have an occupation that is cognitively stimulating.
I saw knitting needles. What does knitting? What about knitting needles? They wave? I see knitting needles in the background. Knitting is a cognitively stimulating activity. So, there are many activities that are cognitively stimulating. There are many things that we can do for our brains that are good for our brains.
Many… so knitting helps to… On the theory of use it or lose it.
Knitting makes you use your brain. That is good for your brain. It's brain exercise. If you exercise your body, that's also good for your brain, it's just a slightly different kind of exercise.
Exercise, what you eat, what you drink, what you don't eat, what you don't drink, how well you sleep. Are you happy? Are you depressed and anxious?
All sorts of factors where you can decide, I'm going to do something a little bit differently. For example. I am… Not actually card-carrying anymore, but a confirmed Coca-Cola addict. And I'm not talking about diet stuff, I'm talking about full, full-on, 100% sugar. When I was in graduate school, I had to drink 6 packs of stuff a day.
About 15 years ago, the research started coming out about just how bad soda is for us.
The sugary stuff? Probably even worse is the diet stuff.
What we didn't know then, and we do know now, and we do know now, is that soda was really the leading edge of the ultra-processed food problem.
I now have a Coca-Cola. I have not given them up. I'm loath to give them up. But I've scaled them back. But soda is wonderful. It's a treat. I have modified myself.
With the exception of the other night, I very rarely eat potato chips anymore. Because that is a pernicious, ultra-processed food. Simple examples, little changes that we all can make every day.
Not every day is gonna be perfect, some days are gonna be better than others. We are all works in progress. The idea, though, is that we have forward motion toward the goal of good brain health.
Audience Questions on Modifiable Risk Factors
Maria Thomas: Yes, ma'am. So, I see uncorrected visual impairment on this.
Let me just repeat the question. She sees on the slide a modifiable risk factor of uncorrected visual impairment, and could Dr. Sanders elaborate?
Dr. Sanders: Sure. If you need glasses, wear them.
If a lot of people have issues with cataracts, it can be very beneficial to get your cataracts, if not fixed. attended to. So be sure that your primary care practice is aware of any eye issues that you may have, and if you have any eye issues, be sure that you're paying attention to them. Dry eye, gotta use drops. If you have glaucoma, different drops. And then…
Most people, certainly I'm this way.
If I'm having trouble with my vision. I am on the phone to my eye doctor yesterday.
People don't seem to react the same way, though, when their hearing starts to go. Lots of loud televisions.
Especially in my house. Untreated hearing loss.
We now recognize as one of the most impactful of the modifiable risk factors for cognitive decline and dementia. I believe
That we are much more likely to prevent These terrible diseases. Then we are likely ever to be able to cure them.
In fact, here's a statistic. If everybody around the world Collectively worked on all their modifiable risk factors.
We could probably prevent Up to 40. 4-0. of the worldwide burden of dementia.
Wow. That's identity.
So that's why we're spending so much time on these modifiable risk factors. At Sunday Health, we really want to take a… preventative approach, and we will, seek folks who have subjective cognitive decline of the sort that Dr. Sanders mentioned. We will see folks who have actual experiencing symptoms and don't quite know what to make of them. Maybe you're concerned because you have a family history. Those are all the types of patients that we see, and that we can assess and provide a brain health baseline. We also have, in addition to Dr. Sanders, we have another neurologists, nurse practitioners, we can help you with the diagnosis, and most importantly, I think, is beyond that, the ongoing care. And when we talk about ongoing care for cognitive issues, oftentimes we are talking about these sorts of things.
And I know, because I'm an older adult myself. I know it can sound like, oh, so now you're gonna tell me to eat right and exercise. Well, yeah, somewhat, but we're gonna try to be more specific about that. So if you tell us hey, you know, I'm Maria, and I have some trouble sleeping, and also I have a little trouble out of one ear. That might be very different from Dr. Sanders, who, you know, already confessed to her various food addiction. So, we're gonna try to have an ongoing, dialogue with you. Think of it like, you know.
When you're trying to exercise your body, you may do that by going out for a walk, on your own, or with a friend. You may do it by going to the gym. And working on your cardio, or working on your balance. You may hire a personal trainer. You may go to a physical therapist. There are a lot of paths to the same goal. The same thing is true for your brain, and so we want to try to instill this idea of… you could call it cognitive fitness, if you want, if that helps.
But it has to do with all of these things. We are going to talk about drug therapies as well, but we really want to elevate this idea that these modifiable risk factors are critical to your brain health. Never too early, never too late. Yes, Ben?
Yes. I've interviewed Russia. 10 minutes.
Yes, so we have been asked to comment briefly on the phenomenon of tinnitus.
Dr. Sanders: So, tinnitus, translated, is simply ringing in the ears.
And, boy, you want to talk about something that is bothersome? Many people find tinnitus to be pretty irksome. And, tinnitus is, is… sort of, you know, neurologically adjacent. It's really in the sandbox of an ear, nose, and throat physician, for the most part, at least in my experience. There are some, physicians, actually, and this is… if you have tinnitus, this is what I would look for, is what's called a neuro-otologist.
N-E-U-R-O-O-T-O-logist. O-to. O-T-O meaning ear.
And a neuro… neuro-otologist may have an audiologist in the office, and they would also have additional things that they could do to… to help, characterize tinnitus, and then sometimes medications help. Tinnitus can be pretty… pretty irksome. It can also interfere with sleep.
So, don't leave before you tell me. I could send you the one in Connecticut. Oh, we can, we can help you, we can help you with that. Yes, ma'am, please.
Maybe this is a bad time to ask, but can you say something about cerebral small vessel disease and its prevalence?
Maria Thomas: Can I, can I just, beg, defer that for a little bit later in the, in the talk? Because I want to make sure we have time for, talking about the new drug therapies and the new blood tests, and then when we open for open Q&A, you can bring that question back. Is that okay?
So, I just want to kind of summarize. We have defined the difference between dementia and Alzheimer's, we've defined mild cognitive impairment, and we've talked about the importance of modifiable risk factors and the importance of getting a brain health baseline.
So let's say you come to Sunday Health and, we need to do a diagnostic pathway with you. We need to determine, do you actually have a condition that can be diagnosed?
So, one of the things that's very exciting that's happening in the field right now is that there are new tools available to help with that. I'm going to ask Dr. Sanders to talk a little bit today about the new blood-based biomarkers.
Blood-Based Biomarkers
Maria Thomas: blood-based biomarkers. Let's start with what a biomarker is.
Dr. Sanders: Right, so… Has anybody ever had… the diabetes test called the hemoglobin A1C.
Yes. Anybody ever have a… anyone who had an APGAR score?
Yep, blood pressure's low. So the APGAR is probably the first lifetime biomarkers that any one of us encounters. And, it is a, grading scale, developed by a neonatologist, I presume she was, Virginia APGAR was her name. And, it just looks at how healthy a baby looks when they, when they initially, left the womb.
That is a biomarker. It is a physiologic dimension that is measurable. That's really all biomarkers. Something very simple, like blood pressure, your blood pressure, your temperature. All your vital signs are biomarkers. Whether you are in pain, this is considered to be a kind of biomarker. Any kind of imaging results. Any… in many cases, genetic results, especially genetic results if they are being looked at to determine whether or not you're likely to respond well to a particular medication. That's a biomarker. Increasingly, in Alzheimer's disease.
most further, most, more fully advanced in Alzheimer's disease than some of the other dementing diseases, but we're working on some of the other dementing diseases as well. And right now, with blood-based biomarkers, blood tests.
So, if you had a choice between going to the commercial lab on the street. Sticking out your arm, and having some blood drawn. Or… having to go to the interventional radiology suite, where you have to lay on your stomach so that the radi
ologist can put a needle into the lower back part of your back and withdraw fluid from around your spinal cord. Which of those two things do you think is going to be easier and more pleasant to get? A blood test.
This is… Huge. So, for a long time now, we have had, fairly sophisticated ways to. see, if you will, the pathology of Alzheimer's disease in a living person.
Fancy, in my kind of medicine, we cannot make a definitive diagnosis of Alzheimer's disease, or any other kind of dementia, unless we have brain tissue to look at.
That means that somebody has died, and the pathologist has looked at their brain tissue under a microscope.
That's not a very, very useful or efficient diagnostic modality. So… when people are alive, we make probabilistic diagnoses. It's probably this, it's possibly that.
And the information that we are getting now from blood tests. Has just been dropped.
progress, I mean, even each product.
I don't know what we've talked over, but we've talked over lots of other tests that would be a lot more invasive, a lot more expensive, maybe even radiation, not as simple as a blood test. We now have one blood test that is as good As good as it's been.
As good as looking at Cerebrospinal fluid. As you would get out of the spinal tap.
and, Probably as good as looking at special kinds of PET scans.
That is one powerful little blood test.
You may have heard that the FDA approved the first ever blood test for Alzheimer's disease back in early May, so just about a few months ago, or almost a couple months ago.
And, this is called the Lumipulse blood test. It's actually a combination of two blood tests that have been around for maybe 18 months to… Maybe a little more than 3 years, 3 and a half years or so. So now we put those two tests together, and that's the new Lumipulse blood test.
And that test is as sensitive and specific, you don't have to worry about what those statistical terms mean, just know that when you have high sensitivity and high specificity in one blood test, or one test of any kind, that is a powerful test. And that is what we now have for Alzheimer's disease.
Most exciting time of my career.
Questions About Blood Testing
Maria Thomas: So we have a couple questions right here. Please, go ahead. So, at what age would you recommend starting, like, a blood test? A question for the online audience is at what age would we recommend getting a blood test?
Dr. Sanders: It's not so much about age, rather it's at this time, and this probably will change in years to come, maybe months to come, but for the time being, it's about whether or not symptoms are present.
So… So, symptomatic. Right, yes. We want to present symptoms. Yes, right. So, at this point, we are, we are…
The clinical practice guidelines instruct us that we should be considering getting that kind of testing when somebody is reporting symptoms.
Now, if somebody has a strong family history, but they don't have symptoms, they may well want to know what their status is on the Lumipulse test. I'm contemplating asking my primary care doctor later this month to do that, and I'll just pay for it out of pocket.
I don't think I have symptoms yet, but I'd like to know my risk, because the other thing that we know is that the pathology of a disease like Alzheimer's disease begins in the brain years
Decades. Plural. That's more than one decade. So, as much as 20 years for the gradual accumulation of pathology. If I have that pathology accumulate in my head, I want to know so that I can even eat fewer potato chips.
Maria Thomas: So, just to clarify, and I'll come to you in a second, at Sunday Health, we do order, as appropriate, not for everybody, but we do order these blood tests. There's more than one, this happens to be the one that has been FDA cleared, but these blood tests look at different types of proteins in your blood, so we order them We order them. They're not difficult, this is why we're emphasizing them. If we ordered one for a patient, it would be as simple as going to wherever you typically go, a lab, like Quest or, like, LabCorp, and just getting this particular type of blood test. So that's all we're talking about. Yes, ma'am? I have two questions. One is whether insurance, specifically Medicare. covers the blood test, and what percentage… Of people who maybe test positive. will go on to get a dementia?
Dr. Sanders: Yeah, great, great question. So the first question was, does insurance cover the blood tests, particularly Medicare?
Maria Thomas: We at Sunday Health have had good experience with both Medicare and Medicare Advantage plans, commercial insurance plans, in getting these tests covered. I can't say 100%, every patient, every plan, all the time, because as you know, in our system, there's always some exceptions, there's always some asterisks, what have you, but in general, we at Sunday Health have had good experience getting, with patients getting covered, particularly with Medicare. And now that the FDA has created this first test called Lumipulse, we're, optimistic that there will be even more coverage for these blood tests. The second question was about what happens if somebody, gets one of these tests, or in general, no matter whether it's with a test or without a test, gets a diagnosis.
What next? Is that your question? No. If they test positive on one of these blood tests, or whatever the marker is… Oh, okay, does that mean… What percentage will go on to get a dementia diagnosis? Okay, so if you test positive with a blood test, what percentage go on to get a dementia diagnosis?
Dr. Sanders: So, these blood tests… And I always, I always quail a little bit inside, cringe, when I read in all the popular literature, the, the new diagnostic test for Alzheimer's disease. That's a misnomer.
There is no single test.
We make an absolute statement here. There aren't very many absolute statements in medicine, but here comes one. There are no… there is no single test.
One possible exception that can make a diagnosis of any kind of dementia.
And the one kind… the one possible exception is an imaging finding in, something called Creutzfeldt-Jakob disease, which is a rapidly progressive dementia that my family happened to have died from. But, it's very, very rare, and really not relevant to anybody in this room.
So, for all of us, there is no test that can make a diagnosis of Alzheimer's disease or any other dementia. A definitive diagnosis, right? No, a diagnosis, period. A definitive diagnosis always requires tissue.
When we order these blood tests, it can't make a diagnosis, why am I ordering a test? I'm making the patient go to the lab and get stuff. Because the information is very, very valuable. So, when I am evaluating somebody, I'm going to look at the whole picture.
And… I was… I'm making a diagnosis. I'm gonna make a diagnosis based on what if things are consistent with one another? What if… what looks to be internally consistent?
What maybe is not internally consistent. So there's now something, called SNAP.
Suspected Non-Alzheimer's Pathology. It's a new acronym, and what it means is
Well, gosh, we have somebody here who has positive bio… who looks like they have Alzheimer's disease, but all of their biomarkers are negative.
Or, you know, something where the biomarkers and the clinical presentation of the person don't match.
So, we're coming up with these new things to describe these situations that we've never encountered before. We are learning as we go. Be patient with us, be gentle. But, so none of these tests can make the diagnosis.
There is a school of thought that says that if you have a strongly positive
Lumipulse test. The Lumipulse, which is two tests in one, is not actually resulted in a single number. It gets resulted in, what's called strata. So, high risk, intermediate risk, or low risk of having excess amyloid, one of the… proteins that goes rogue in the brain to cause Alzheimer's disease. You have excess amyloid, that's what the Lumipulse test tells you the likelihood of whether or not you have excess amyloid in your brain.
A high likelihood clinical success means you probably have amyloid. A low likelihood means you probably don't. It's that intermediate. that we just really don't exactly know what that means yet. We know, too, that there are cases of people with positive blood tests Asymptomatic.
And they've been, not clinically, but in clinical trials, in research. They've been followed for years. They don't develop symptoms. We want it to be called now.
There's one school of thought that says once you have a positive biomarker, you have the disease.
I personally do not subscribe to that school of thought. I find that to be a little bit overly deterministic, because I would find it very, very hard to say to somebody, look, I think you have Alzheimer's disease, when the person is completely asymptomatic.
That's not something I want anyone ever to say to me, and I'm not going away at saying it to other people, but there is a reasonable, rigorous argument that says that's what we should be telling people. There is another school of thought, and I might be more a member of this one.
It says that we should be looking at things like biomarkers and blood test results as part of the bigger picture, and really, you know, looking at the whole person.
And, so then making a diagnosis that really sort of represents what's going on.
Not what might happen 20 years down the line.
New FDA-Approved Drug Therapies
Maria Thomas: So, thank you. I see a couple more hands. If you would bear with me just one moment. I just want to get through one other very important topical area, and then we'll turn and open it up for questions, so we're almost at the hour, so maybe we can just try to quickly cover this. And those are the two new FDA-approved drugs that I had mentioned early on. These drugs have been approved by the FDA. within the last 3 years. One is called Leqembi by brand name. Dr. Sanders will give you the official names. The other's called Kisunla by brand name. These are both infusion therapies, meaning that you need to go sit in a chair, get an IV, and receive a drug.
These are really, exciting. They're not for everybody, and Dr. Sanders could explain that. Why do I say exciting? Because they're the first two new FDA-approved drugs that are disease-modifying drugs, meaning they're not addressing the symptoms of the problem, they're actually trying to address the underlying pathology. So, just a few words on Leqembi and Kisunla.
Dr. Sanders: Yes, so, these are called monoclonal antibodies, that's just the term that you, the mechanism for how these medications work. In order to be eligible for them, their, eligibility determination is, detailed.
you must have either mild cognitive impairment or a mild stage of Alzheimer's disease.
They are not for… dementia diseases other than Alzheimer's disease. The underlying must be due to underlying Alzheimer's disease. You can have MCI that's due to something else, must be due to underlying Alzheimer's disease, or the mild stage of Alzheimer's disease, and then you must not have
Certain other exclusionary factors. For example, you cannot be on a blood thinning medication, because one of the side effects of these medications can be, brain bleeding. So, we want to be very, very careful. And…
These are the first ever, it's not just that they're new, the first ever, in recorded human history, disease-modifying medications for a disease that causes dementia.
Maria Thomas: Thank you for that. So, at Sunday Health, we, we can, through experts like Dr. Sanders, help you determine if you do have cognitive impairment, for example, and if you might qualify for one of these therapies. We can help you with that, if that's something you're interested in. We, partner with a group called Re:Cognition Health, where they have an infusion center, and they specialize in that. Re:Cognition Health also happens to do clinical trials for MCI and Alzheimer's disease, so that's something of interest as well.
Re:Cognition health as our partner and collaborator, and all of this is, as we look to be preventative.
So we're at the hour, I just want to… a couple of little housekeeping things, and we'll go to questions. I know a number of you are interested in the slides. If you registered for this event, you are going to receive a copy of these slides.
And if you didn't register for this event and you want the slides, you can see our colleague Marissa, who's in the back, and she can make sure to get your email so we can send you the slides. Also, if you or anyone you know in your friend or family group, would like to make an appointment with Sunday Health, we can also talk to you afterwards, you can just very simply go to our website, we'll present that information here. Very easy to call us, make an appointment. We do take insurance, Medicare, Medicare Advantage, and commercial insurance. So, just wanted to make sure I got that information out, since I know some people might need to leave at the hour.
Q&A Session
Maria Thomas: Now, let's turn to questions. I know there's a couple hands in the room, and we also have some online questions, so if you see me looking at my phone, I'm reading the online questions. Yes, sir? Dr. Sanders, under what circumstances would an autopsy be helpful? In other words, like. If you have a family member that's passed away with dementia, under what circumstances would you… would an autopsy be helpful to make the diagnosis, for example, one of those four types of dementia?
Dr. Sanders: Sure. So, the question for our online audience is, under what circumstances would an autopsy be helpful?
If you can find a neuropathologist to conduct the autopsy, an autopsy is always helpful. It is the only way to be sure of what was going on.
And we're pretty good in life at making diagnoses now much better than we were even when I began my career in 2008.
But we're not perfect, and Alzheimer's disease is a tricky, wily little beast, and not all… everything that is Alzheimer's disease shows up walking and talking, like.
I'm Alzheimer's, sorry, I apologize for the flaming metaphor. I'm gonna go over here and then come back, I see a couple over here. There was someone over here who had a question? Yes.
Yes. Where does, dementia associated with Parkinson's fit on there…
So, yes, the question is, what about dementia?
Try that again. Okay, there we go. The question is, what about dementia with Parkinson's disease? Earlier, I mentioned dementia with Lewy bodies.
And dementia with Lewy bodies and PDD, Parkinson's disease with dementia, are kissing cousins.
And the only thing, really, that distinguishes between them is which came first, and by how long. If the motor symptoms. which are typical for Parkinson's disease, show up first, and by at least a year, and then later, the person with Parkinson's disease develops dementia, which is not always, but frequent in Parkinson's disease. Then we call that Parkinson's disease dementia.
If… cognitive or behavioral, when I say behavioral, I frequently mean things like visual hallucinations and, acting out things you're dreaming about at night, which is not normal.
those sorts of behavioral manifestations or cognitive manifestations, if those show up first, like what you see here, and the physical aspects of Parkinson's disease, what we call Parkinsonism.
come later, then we call it dementia with Lewy bodies. So dementia with Lewy bodies and PDD are really two sides of the same coin, or two ends of the same continuum.
Yes, I'm gonna, start here, and then we'll come back here. Please.
Sort of.
The question was, is Alzheimer's hereditary? So, there are certain genes that have genetic mutations, and if you are unlucky enough to have a genetic mutation.
Your destiny is fixed. You will get Alzheimer's disease.
But most of the genetic… impact, but most of the genetics in Alzheimer's disease are not deterministic genetic mutations. Most of them are related to, risk. enhancement. So, many of you may have heard of the famous ApoE gene, which many people think of as the Alzheimer's gene, but that is a risk gene.
It is not a destiny gene. So, if you have one of the variants of the ApoE gene that increases your risk, that's all it does. increase your risk.
Note to self, you might want to work on those modifiable risk factors if you know that you are at increased genetic risk.
the ApoE gene is not destiny, and there are, large research studies that have examined people who lived to be 95 years or older, had 2 copies, so the highest possible risk profile.
Smoked, drank, didn't go very far in school, cognitively intact.
So, clearly those people have some kind of a protective factor, we just haven't found yet, and boy, are we looking for when we do. So the short answer is, kind of. But, so if you have a first-degree relative, sibling, parent.
That probably means that you are at a little bit increased genetic risk relative to somebody who does not have that genetic risk.
How would the blood test show? not the Lumipulse test, but if we run your ApoE genotype, which we now do all the time. We used to not do that because there were no disease-modifying therapies. So the teaching was, don't get the genetic test, because
There's nothing we can do about it. And now, that is all different.
Maria Thomas: You start there, and then go to you. I have a question about vascular, the cerebral small vessel disease. What causes it, and once it's there, what do you guys do?
Dr. Sanders: Yes, so the question is about what is cerebral small vessel disease, what causes it, and what do we do about it?
And cerebral small vessel disease. Probably the vast majority of us have some degree of it in our brains, because it comes from
Disease to small blood vessels. Capillaries, arterioles.
Usually caused by the same things that give you heart disease. Diabetes, high blood pressure, high cholesterol. That gives you disease through what we call the white matter. That's the cerebral small vessel disease. Cerebral large vessel disease, you know by another term. That's a stroke.
You have a large vessel that becomes occluded, a very, very small vessel that's gonna choke out the blood supply to a part of your brain. That gives you large vessel disease or stroke.
Small vessel disease, most of us have. The vast majority of people with Alzheimer's disease also have small vessel disease. And,
Isolated Alzheimer's disease is actually a fairly uncommon, maybe even rare, phenomenon, but in combination with vascular disease, very, very common.
What is different about cerebrovascular disease is that it is now not a neurodegenerative cause of dementia. If it is widespread, it can cause a dementia.
but not a neurodegenerative one. So if you can control your vascular risk factors.
Diabetes, blood pressure, cholesterol, you can prevent yourself from, or you can potentially prevent your cognitive decline from getting worse.
What is different about the treatment of small vessel disease now, compared to
I have to go back to when the guidelines changed, but certainly a decade ago, we used to prescribe aspirin, a baby aspirin.
Pretty much, if you turn 50, somebody was gonna start telling you, take baby aspirin every day.
We don't do that anymore. Those guidelines have changed. That's one of the great things about medicine. It's not fixed. We learn all the time, and one of the things that we learned was that there were more bleeding events for having all those people on aspirin.
And, cognitive decline wasn't better.
Maria Thomas: Thank you. I know you have… I'm sorry, can we follow up, perhaps, in the one-on-one after, just… we're way over time, and this woman would like to ask a question? Have I understood it correctly?
You mentioned would not qualify for the two.
The question was, would a person with Parkinsonian dementia qualify for one of the two monoclonal antibody treatments? Yes, you did understand that correctly. A person who has PDD, or DLB, would not, be eligible for one of these medications. They are for mild cognitive impairments, thought to be due to underlying Alzheimer's pathology, or mild Alzheimer's. So we're going to take two more questions. and then I have questions for you. So this gentleman, and then over here. Yes.
I'm just wondering, is your, like, parents? And my grandparents didn't have any dementia.
Could I still get it? The question is, if the parents and grandparents did not have symptoms of any form of dementia, could you still get it?
Dr. Sanders: Yes.
Maria Thomas: Okay, yes, sir. Are they qualified to…
I love this question. The question is, are the longevity centers that are cropping up around the country qualified to help with brain health? And I love the question because it's relevant, and also because it leads me into my questions for you.
I think… I'll give you my answer, and then Dr. Sanders will likely want to add something, but I think longevity is one of those words that can mean different things to different people.
And so, a longevity center, I'm not sure we have a common definition in our collective understanding of what that is. In some places, there may be longevity centers around that have physicians, medical doctors, like Dr. Sanders, in the center, and perhaps they are addressing brain, brain health and preventative cognitive care, I don't know. But I do think also there is a whole wave right now in our culture that is longevity more related to,
the non-medical, or at least not traditional clinical factors that may have to do with some of the same things we talked about, like diet, exercise, etc. So, in my view, I don't know that there's a common answer to your question that's well understood.
Dr. Sanders: I think the only thing I would add is, sort of caveat emptor - let the buyer beware. There probably are some places that are not so good, and other places that probably would be good. And I would say, if you're shopping for one, find one that's not just going to do the diagnostics. Find one that's going to teach you what to do with the information that they give you. How to make yourself more likely to live longer.
Closing Remarks
Maria Thomas: I want to thank everybody for, attending here, and all of those who are online also. I want to thank Dr. Sanders for her fountain of knowledge, and I want to thank Shaun and the folks at Inspir for this amazing setting, and thank you all again for attending. We'll stick around for a few minutes. Any questions.
Thanks for a great program. That was, amazing, and obviously the work that you guys are doing is, following through on the promises. So, I think that's what will differentiate Sunday Health's menu. So, thanks again, everybody.
