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Kristy Kennedy and Ginger Noce: Hello, everyone, and thank you so much for being on this great webinar today on a rainy day in DC. If that's where you're coming from. I'm Ginger Noche, and I'm Christy Kennedy. We're with silver bridges consulting, and we really appreciate and an honor that you are here today. Silver Bridges is, we are private consultants that work with families and with identifying and selection of senior living communities here in the area and across the country, and one of the goals of our organization is to find experts field experts on topics that are most relevant to you. And boy, do we have a wonderful guest today had the pleasure of meeting CEO Maria Thomas about a year ago, at an Alzheimer's walk, and started talking about what Sunny health was doing. She started talking about Amy, Dr. Amy Saunders on the call.
We just really are just so impressed, and are just privileged to offer this great topic to you today. So without further ado.
And I want one thing just for a housekeeping, if we love questions. So if you would please any questions you have throughout the presentation. And, by the way, thank you for your input already and things that you want to learn about. If you go to the bottom of your screen, you'll see Q&A. And if you just write those in we'll be able to look at them and incorporate them to the content. And if there's something that we don't get to the most appropriate person on the call who has that level of knowledge will respond to you privately after the after the event. Today. This this meeting is being recorded. Everyone on the call will get a recording. So no worries there. All right, Maria, I'm going to turn it over to you.
Maria Thomas: Thank you so much, Ginger, and thank you, Christy. We're honored to be with everyone this evening, and thank Silverbridges for inviting us to share what we're doing at Sunday health, and to share the deep knowledge of Dr. Amy Sanders. My name is Maria Thomas. I'm also in Washington, DC. As Ginger mentioned. I'm the CEO and non-clinical leader of Sunday Health.
And I'm joined by my colleague, Dr. Amy Sanders, tonight. Dr. Sanders is a highly experienced dementia neurologist. She's been practicing for over a decade and a half. She'll tell you exactly how long. But you'll soon find out that she is a true expert, not just in neurology, but specifically with respect to issues of cognition or memory and thinking. So just a quick word about Sunday health. And then we'll get started. Sunday health is about a year and a half old. We are a specialty neurology clinic.
Hopefully, everyone can see these slides. Please let us know if you cannot. We are especially neurology clinic. And we really focus in on, as I mentioned, issues of cognition, memory, and thinking with a special interest in trying to prevent and delay any kind of cognitive decline. But we have a full range of services that include cognitive assessing, cognitive assessments. Excuse me, diagnostic being able to diagnose, and then, most importantly, a longitudinal care model meaning, we take care of folks in a way that is pretty hands on, and Dr. Sanders will share more about that. We are currently operational in DC. Maryland, and Virginia. So that's our region. At the moment we have ambitions to expand. But right now we're in DC. Maryland and Virginia.
We offer appointments in person in Vienna, Virginia, and then we service anybody throughout the region via telehealth.
We do have cognitive neurologists on staff, including Dr. Sanders. We also have nurse practitioners and care navigators. So we'll be happy to answer any further questions. Oh, very importantly, we take insurance, including Medicare. So we'll be happy to answer any further questions about our services as we move through the program.
Just to let you know how we're going to do this. I'm going to ask Dr. Sanders a number of questions for about 15 or 20 min, maybe a little bit longer. We're going to try to get through all of the questions that came through in advance of the webinar, and then we'll definitely leave time for questions that come through now as they occur to you.
So to get us started, Dr. Sanders, there were a number of questions that came through about what is the difference between normal aging and dementia, and if I could, could you also please define dementia.
Understanding Dementia vs. Normal Aging
Dr Amy Sanders: Sure. Thank you, Maria. I'm delighted to be here this evening, so my thanks to both Ginger and Christy for the invitation, and I hope that everyone who is listening learns what you're hoping to learn this evening.
I love starting with what is dementia? Because, in fact, seems like a simple term often misunderstood.
Dementia is not actually a disease.
It is just sort of a catch-all term, an umbrella, if you will for cognitive decline. That has become significant enough, has progressed to a degree where it is beginning to impair a person's ability to live their lives and take care of themselves in their normal way. Whether that means remembering how to make Mom's spaghetti sauce, or how to drive down the coast to South Carolina, how to pay the taxes.
Whatever makes a person. That person begins to come under attack from dementia, and that is all dementia means is that somebody's ability to live their lives in the way that they want to live them and are accustomed to living doesn't work anymore.
So dementia is kind of the unhappy, long-term trajectory that some people find themselves on as they get older. There are a few lucky people whose cognition really doesn't change very much as they get older.
We consider them really to be a variation on the theme of sort of super agers if you've ever heard of that. But most of us do. Experience changes. I mean, that makes sense right? Our hair changes, our skin changes. Lord knows, our joints change as we get older. So it stands to reason, and, in fact, is logically true that the brain ages as well.
So typical things that happen, and that we consider a normal part of the aging brain.
People might struggle longer to learn how to work the new Gizmo. Probably the best example these days would be getting a new mobile phone and having to figure it out. I used to ask people, can you program your own VCR,
and for most people, people, even as we get older, we can still do those things might take us a little bit longer than it used to taking longer is normal.
Being able to do it the same way that you always did when you're in your seventies. Being able to do things as well as you did when you were in your thirties. That's not bad, but it ain't normal, because most people don't have that very, very successful aging trajectory. Most of us pick up a little, you know little digits here and there, so we may struggle to remember the word that we want it in the moment that we want it.
That happens. A lot happened to me once took me 6 months before the word came back, but eventually it did come back that we call the tip of the tongue phenomenon. And if you leave here this evening, understanding one thing about the typical aging process of a normal brain is that the tip of the tongue? Phenomenon is one of the most classic signs of the aging brain. What was that actor's name. Where was the good restaurant where we had that really, really, really wonderful fettuccine?
And then, 10 min later, oh, gosh! That's right!
Or or 6 months later. Still, the same thing that often happens.
If, on the other hand, you are starting to experience things that maybe are are a little alarming.
All of us lose our keys if they wind up in the freezer.
Might be time to come. See someone like me.
Maria Thomas: Thank you so much, Dr. Sanders, for that clarity. I want to just maybe put a fine point on something. So what you're saying, if I understand you correctly, is that cognitive decline, or you know, memory decline is not normal aging. Is that correct?
Dr Amy Sanders: That is absolutely yes, and and thank you so much for for really underscoring that because we used to think that memory decline was a normal part of aging. If we were having this webinar 40 years ago. Obviously we couldn't do that. The technology didn't exist. But play with me if we were having this conversation 40 years ago, we might have talked about the kinds of memory that memory, dysfunction, or memory decline that are normal parts of aging, but we know better. That's what science does. It learns things over time, yes, and over time. We have learned that memory loss is never a normal part of the aging process. If you or a loved one is experiencing memory loss, get help. There is help. Help is available.
Alzheimer's Disease and Mild Cognitive Impairment
Maria Thomas: Thank you, Dr. Sanders. I want to acknowledge I do see that a question came through in the Q. And A. I just I should have mentioned upfront that we won't be able on zoom with, you know, dozens and dozens of people here to answer specific medical questions. That's not something we can do in a group setting. So forgive me for not mentioning that up front. But if you have more generalized questions, we'll be happy to take them.
So coming back to you, Dr. Sanders, so you've explained that dementia is an umbrella term. Why do we always seem to hear Alzheimer's disease kind of interchangeably used with the word dementia.
Dr Amy Sanders: Well, it's sort of you know what what happens commonly gets all the attention. So
I've never actually counted. But were I to count, I could probably come up with close to a hundred different conditions that cause the dementia syndrome and Alzheimer's disease is the big kahuna. It accounts for the vast majority of cases of dementia. So most people who have dementia have it because they have Alzheimer's disease, and then the 2 terms often get conflated. So it's not so uncommon for me to, you know. Have somebody sometimes a patient, sometimes a family member say, well, you know.
Is this dementia? I mean, it's not Alzheimer's disease, thank God!
But you know the the lines blur in in the terminology. So Alzheimer's disease is the single most common dementing disease. But there are many others.
Maria Thomas: Thank you, Dr. Sanders. And then what is this phrase that we hear often mild, cognitive impairment.
Dr Amy Sanders: Yes, so mild, cognitive impairment, and when you say that phrase to yourself in in your head, be sure to capitalize the M. And the C. And the I, and then you will get to the way that we are shorthand, for we we call it mci. For short.
Mild, cognitive impairment is an invented diagnosis. It was invented by a neurologist who realized nobody goes to bed on Monday night with normal cognition, only to wake up on Tuesday morning with full-blown Alzheimer's disease, he realized that there had to be some sort of transition state through which people passed from normal cognition to the earliest stages of Alzheimer's disease, and he called that state mild, cognitive impairment. I won't bore you with all of the specific criteria for making that diagnosis, but you can think of it sort of as the waiting room between, you know the waiting room to get to Alzheimer's disease. You probably don't want to go into that room.
No kidding you in the waiting room as long as possible, and there are ways that we can help you do that. So mild cognitive impairment is an in-between transitional state between normal cognition and the earliest stages of any kind of dementia.
Maria Thomas: Thank you, Dr. Sanders, and I might add that I think this is correct, and Dr. Sanders will correct me if I'm wrong, that is to say that not all cases of mild, cognitive impairment develop into full blown dementia.
Dr Amy Sanders: That is correct, and we sort of slice and dice mild cognitive impairment into mild, cognitive impairment that does involve memory and mild, cognitive impairment that does not involve memory.
Memory involving mild, cognitive impairment, might progress more frequently. If it does progress, it progresses typically to Alzheimer's disease.
And there are now many new ways that we can ascertain whether somebody's mild, cognitive impairment is likely to be due to underlying Alzheimer's disease.
There'll be more about that in a little bit.
Maria Thomas: There will.
Dr Amy Sanders: But the non-memory involving, or, as we call them, the non amnestic forms of mild cognitive impairment, often can back transition into normal cognition if we can correct the thing that was causing the mild, cognitive impairment.
I read a paper a long time ago that said that aberrations in parathyroid hormone was the most common thing. That is not my clinical experience, but poor sleep. Too much stress. And, you know, not exercising depression and anxiety. If we can treat these things. We can sometimes help people sort of regain normal cognition.
Memory Loss and Genetics
Maria Thomas: We're going to come to those again, and I'm going to call them modifiable risk factors. So remember that term. But first, st Dr. Sanders, we have 2 questions that have come through, and I think they're both fit in right now. One is, what is memory loss.
Dr Amy Sanders: All right. Memory is one of the 5 main types of thinking.
Attention, memory, language, reasoning, abilities, and being able to interpret and manipulate visual and spatial information.
Those are not hermetically sealed categories. The colors run. So there's a lot of overlap. Memory is our ability to learn from experiences and apply that knowledge sort of in the future. In order to apply the knowledge in the future, you must be able to remember what you learned in the past
Memory comes in different flavors, though there is memory for things that you might say out loud or write down. There are also memories that are more procedural. How do you cut an onion? How do you ride a unicycle?
Different kinds of memory, even when we're talking about more verbal memory? Even then we can talk about it in terms of time. Frames. Working memory is the ultra ultra short term memory kind of memory. You need to kind of memory you rely on in order to recall the digits of a telephone number before you press them into your phone.
There's short term memory what I had for dinner last night
I made a stir fry, by the way, and then there's long term memory. When I graduated from high school where I graduated from high school, what I wore to my high school graduation, and in Alzheimer's disease
Short term, memory is affected first, st so people frequently say, Oh, grandpa, you know he can remember everything that happened to him in high school, but he can't remember how to get home from the bank.
That's typical. That's common. That's that's problematic memory trouble.
Maria Thomas: Speaking of grandpa, there's another question related to the is there I'm going to paraphrase, is dementia inheritable? Is there a genetic predisposition for dementia? And in answering that question, Dr. Sanders, could you also speak to the genetic test that is now available.
Dr Amy Sanders: Yes, so actually, that genetic test has been available for a long time, but we never ordered it. Because and this was the consensus, thinking we don't order that test because we don't have any disease modifying treatments.
That's different now. So now we do order that test a lot, and it's 1 that you might have heard of. It's the test for apoe.
The problem with apoe testing is people here. It's a genetic test, and they immediately think of genetic diseases. If I have this genetic marker, that means I'm going to get the disease right.
Not for apoe apoe is what we call a vulnerability enhancer. So the way that apoe works I'm going to make this short and sweet. You get a copy from Mom and a copy from Dad. But they each have 3 versions that they can give you, so I usually reason, by way of Neapolitan ice cream vanilla, chocolate, strawberry. You get one of each from mom and one of each from Dad, and that gives you your apoe genotype.
The 3 versions are, we call them Epsilon. Epsilon is just the address in the gene. Where this little change occurs.
Epsilon, 2. Epsilon, 3. Epsilon, 4. Epsilon, 2. Very uncommon, probably protective epsilon, 3. Neutral epsilon 4.
Problematic if you have one. Your increase, your risk for developing Alzheimer's disease is probably 2 or 3 times that of somebody who does not have one of those markers. How do you fix that? How do you address that? You work on your modifiable risk? Factors? Your genes are not modifiable, I mean, your dungarees are, but not your genetic profile.
So if you have 2 copies, if you get an E 4 from Mom and from Dad, then your risk for developing Alzheimer's disease could be as high as 25 times that of somebody who does not have that marker. But this is not the same as a genetic mutation. There are genetic mutations in Alzheimer's disease, and in several other forms of dementia. Those, though, are so vanishingly rare that you've probably never encountered a person who has one of those mutations.
But people who have apoe polymorphisms because it's called a polymorphism, because there are multiple, different ways that you can have it. If you have this polymorphism that's very common.
Thank you. Complicated stuff.
Early Detection and Testing
Maria Thomas: Thank you. In the advanced questions that came through there were quite a number of questions regarding testing and diagnosis. So I'm just going to ask a few of these. We tried to group them together. And basically, I guess the 1st question is around, what are the best ways to detect cognitive decline, mild, cognitive impairment or dementia early. What should someone do if they want to get in front of this.
Dr Amy Sanders: Yeah. So there is a a famous old expression in quality development in in medicine. If you don't measure it, you can't modify. It goes something I'm paraphrasing.
So the 1st thing that people have to do is pay attention.
You know, we all go to the dentist twice a year.
We all get colonoscopies every 3 or 5 or every 10 years. We fret and worry about our heart health.
We don't give our brains a second thought, so the 1st thing that is important to do, and this is this is one reason that we're here this evening is is.
Please think about it.
Please go home and tell all your friends how important it is to think about the health of your thinking
Really really matters. You can't get out of bed in the morning, if you're not thinking clearly. So that's the 1st thing is just, you know, having that that basic sort of spidey sense awareness, knowing what your own abilities are, and where your own problem areas lie.
I don't sleep well.
I have to work on that
Since I learned things about nutrition and dementia.
I don't even need the fingers on a whole hand to count the number of times I've eaten potato chips, so we are all a work in progress, and much of that work that we do can help us protect our precious, precious, precious cognition. If you are noticing changes, if you are noticing changes in loved ones.
Please suggest, help them get assessed.
We have to. We have to take your cognitive temperature before we can do anything else.
And people often say, Well, there's no point in doing that, because nothing can be done.
Nothing, in fact, could be further from the truth.
Even even in the end. Stages of these terrible diseases.
There's help.
Blood-Based Biomarkers for Alzheimer's Disease
Maria Thomas: Thanks again, Dr. Sanders. We're going to talk about what some of those things that can be done are. But 1st I want to go a little bit deeper into the tests that you mentioned. So you were just encouraging people to pay attention to your cognition. Notice changes and then get a test. If you see that there's a problem in your own memory or thinking, or in that of a loved one. There were a number of questions that came through about blood tests for diagnostic purposes, for dementia. Maybe I could broaden it out and ask you to speak about what are the blood tests? What are they looking for, and what are they? A definitive tool for diagnosing? In other words, how would we then diagnose so what are the blood tests? What are they looking for? And how do we actually diagnose.
Dr Amy Sanders: Yes, so it is very, very exciting that we even get to have a conversation about blood tests for most of my career. The blood tests that I was instructed by things like clinical practice guidelines and that sort of thing to do were very basic. Get a vitamin. B 12 level. Make sure people's thyroid glands are functioning. Okay.
Once upon a time those were taught to medical students and physicians in training as the reversible causes of dementia. By the time I got to medical school I graduated in 2,002. They were teaching. Well, they're not really reversible. But if there's cognitive impairment and you find a problem and you fix it. The impairment might get a little bit better. Well, now, we have tests that actually can look at the likelihood that somebody is developing the pathology of Alzheimer's disease in their brains.
Mind blown big, deal big changes.
For the past couple of years we have been able to look at the ratio in a person's bloodstream of bad Alzheimer-like amyloid protein to normal amyloid protein. We all have normal amyloid protein.
Some of us are unlucky enough to also have that bad Alzheimer-y amyloid protein.
Amyloid protein is one of the neuropathological hallmarks of Alzheimer's disease, especially when it gets deposited into the brain in the form of what are called plaques.
Amyloid plaques.
Amyloid, deposited into the brain tissue. That means, then, that there's less of that bad amyloid protein to circulate in the bloodstream.
And so then we can look at the ratio of bad amyloid protein to normal amyloid protein. And we can do that over time.
And when that amyloid ratio drops below a certain level.
Then we consider that to be a positive test, it means that the implication is that people are depositing amyloid protein into their brains in plaques. That was the 1st Alzheimer's disease specific blood test that came into existence. It was not FDA approved.
But we've been using it. When did I start using it? Probably for about 3 3 and a half years? We now have the ability to test also for 2 isoforms or variants of the other protein that goes sort of rogue in Alzheimer's disease, the tau protein. Here's where it gets a little bit weird even when we check one of those Tau tests. What it's actually telling us is how likely it is that a person has amyloid protein amyloid pathology in their brains. There are some other tests that we're also getting now. I mentioned the Apoe genotype. That's we get that.
I get it almost as a reflex now, because it helps me to know. And then for the some of the new disease modifying treatments, the Apoe genotype is is relevant.
So that's a test that we get. Commonly we now have been getting the amyloid ratio, and these Tau isoforms for the past couple of years.
About 6 weeks ago, maybe not even quite 6 weeks ago, the FDA approved for the 1st time ever a new blood test.
It's not actually a new blood test, because it's a test that now combines several of the tests that we have had. This new test combines that amyloid ratio and the one of the Tau tests the better of the 2 Tau tests. And so now we can do one blood test.
And we get as much information more actually than we used to get when we did 2 blood tests. So this is truly a case of the whole being greater than the sum of the parts.
That's that was the very, very big news that happened. It's the 1st time ever that we've had an FDA. Approved blood test in dementia, let alone I mean dementia writ large in Alzheimer's disease in particular.
However, I also need to be specific about when and how you should think of this test being used. It is not something that you should be marching into your primary care doctor's office and demanding if you're asymptomatic, they ain't going to give it to you.
Because all of the teaching, all of the instructions. All of the guidelines about these tests is that they should be ordered and interpreted in a specialized practice that is familiar in working with them. So this is new stuff, and we're learning more and more every day. So I may know more than your primary care, physician. But I'm going to learn new stuff tomorrow or next week.
Maria Thomas: So, Dr. Sanders, maybe you could just say one more thing about these blood tests which, by the way, for everyone listening at Sunday, health we order and have been ordering even prior to the FDA. Clearing the test, because, as Dr. Sanders mentioned, there are many blood tests, and the fact that they have been. At least one has now been approved by the FDA. We do expect others to come in the future, and we do expect clinical guidelines for primary care to be ordering these tests, possibly as soon as later this summer. But, Dr. Sanders, maybe you could mention as well what does this as you as you're a practitioner in your diagnostic tool set. How do you use the tests combined with other things? And what does the test allow you, perhaps to not do or make a shorter time to diagnosis. Perhaps.
Dr Amy Sanders: Yeah. So these tests are often written about in the news, and that sort of thing as being the new diagnostic tests for Alzheimer's disease. And that's kind of true. But please do not think of them that way, because, in fact, none of these tests has the ability to make the diagnosis they are.
I was just going to say they are but one piece of the puzzle. And and here's this lovely slide that I only just now noticed, has puzzle pieces all over it. So yes, blood tests.
Neuroimaging. So I'm a neurologist. I love me some Mris of the brain
Cerebrospinal fluid. Not so much anymore.
You used to have to go and get a spinal tap.
And I really think that for the vast majority of situations spinal taps are no longer going to be needed. I can't remember the last time I ordered one.
And that's an invasive procedure these days. It's spinal taps are almost always done in a radiology suite. So it also means a big, fat dose of radiation. It's a test that nobody really wants to have. And, boy, if you can have a simple blood test instead.
That's progress.
And that is incredibly exciting, incredibly helpful progress. But the blood test is still just one piece of the puzzle. So we want those biomarkers, those what's happening in your blood, what's happening in your brain? But we also want to see, how are you functioning.
So you should have an in-depth, or anybody who's worried about their cognition really needs an in-depth assessment. So not just a cognitive screening test.
Or at the very least, you must have Plan B. If your cognitive screening test comes back with a positive result.
But to assess somebody, especially an older adult for cognition. We also have to take into consideration what's their mood like? What's the diet like? Are they exercising? Are you sleeping at night?
Other medications that could have side effects. So it really is. None of us can be reduced to a single test. None of us should be so. The evaluation really of the of the thinking brain is an in-depth, comprehensive, holistic process. And you know, a patient said to me a couple of weeks ago.
And I'm going to blow my own horn here, because, she said, you know, you're the only person who ever looked at the big picture.
That's what it takes.
That's what we do.
Timing of Cognitive Assessment
Maria Thomas: Thank you, Dr. Sanders. There are a number of questions that came in earlier and also now online about essentially, I'm going to summarize them as what's the right time to get a cognitive assessment? Is there a specific age? Should we start at a specific time? I know what you're going to say, but I think you should share that with everyone.
Dr Amy Sanders: Yes, so I'm quite actually, I think, infamous for saying that if I were king of the world.
Which is, of course, not likely to happen for all sorts of reasons, but if I were, everybody would get their 1st cognitive assessment when they were in their mid thirties. Why do I pick that time. Well, it takes almost until our late twenties for our brains physically to be fully mature.
And then, you know, add a little 5 to 7 years for for the accumulation of some lifetime, wisdom, or some lifetime experience that will be the foundation for the wisdom that one will have later in life. So really, when you're in your mid thirties, that's as good as it's going to get.
And after that that process of normal, cognitive aging begins to take over, and you begin having things like, what was the name of that movie? Or you know, why can't I sleep as well as I used to, as we say in my house. A lot young is better, and it's also, you know, kind of stupider. So there are benefits to being older. Don't forget those.
So anyway. The mid thirties is when everybody I would love it if everybody could have an evaluation. It's interesting that in my practice alone, and I'm talking just in the last few months. Really, I'm starting to see what I think of now as the youngsters people coming in in their forties and their fifties because they've heard of the new blood test because a parent has Alzheimer's disease, because somehow they've gotten wind to the existence of modifiable risk factors.
What has also been interesting to me is that, despite the fact that these people are coming to see me worried.
Their modifiable risk, factors are in a shambles. So another reason to start thinking about this earlier is so that you can start doing all of the important things that we don't necessarily connect with brain health, but that are essential for brain health. Got to start doing them early.
Cognitive Assessment Tools
Maria Thomas: Thank you. We're going to switch gears and talk about treatments before we do that. There was a question here now about, are we still using the Moca or the Mmsc. So if you could answer that, Dr. Sanders, and maybe mention also the development of digital cognitive assessment tools, and how we at Sunday health combine the 2.
Dr Amy Sanders: Sure. So yes, I would say that the Moca, which that's an initialism that stands for the Montreal cognitive assessment. It is probably the single, most ubiquitous, cognitive assessment tool in clinical practice today. Not my favorite tool, however, because it's very, very good at picking up problems with reasoning that may often have underlying vascular causes high blood pressure, high cholesterol diabetes, heart disease.
That's not typically, though how Alzheimer's looks so Alzheimer's there's a different test that I prefer. If I'm sort of chasing after the kind of memory problem we might see in early Alzheimer's disease or in the waiting room for Alzheimer's disease that mci, I spoke about earlier. The Mmse. Is actually that's the Mini mental state exam. Once upon a time it was the single, most commonly used cognitive assessment tool. I think really the only reason that it still exists is because a lot of older physicians learned it and can teach it to their students and trainees, but also because it is frequently used in research and clinical trials. It is, however, quite problematic, because it's too easy for most people, and it's also very, very highly biased sort of culturally. So we now have better tests. The Moca. Actually, one of the reasons the Moca was developed was actually because of that the cultural biases that were known to be a problem with the Mini Mental State exam.
There are many, many other ways that you can do that sort of brief assessment. It's not a full, comprehensive assessment, but it's a little bit better than just asking somebody to remember 3 words. All of those tests are a little bit more in depth. I actually have my own made up test that I use instead of either the Moca or the Mmse. And
These days digital cognitive assessments. Also increasingly wearable cognitive assessments. Sort of think, apple watch for cognition. Those are not. You can't go to Costco and buy one of those just yet. Those are pretty much in the purview of research still. But digital cognitive tests are all over the place. So there are a number of different platforms. I'm not going to be able to remember the names off the top of my head, but the way that we set things up at Sunday. Health is the 1st thing that somebody does is one of those digital platforms.
Then they come and they have an initial, an initial cognitive assessment either with the Moca or with my made up version. And then, if that assessment reveals problems, then they might be referred on for what we call neuropsychological testing, which is much more in depth.
Maria Thomas: Yes. So the digital cognitive assessment tool that we use at Sunday health is called brain check. It is a validated tool that, as Dr. Sanders said, there are many in the market. If you were to come through the Sunday health process, as she mentioned, we would ask you to do the brain check prior to your 1st appointment. And this would sort of feel like playing games.
And one of the interesting things about the digital cognitive assessment tool is that there's a good deal of research suggesting that they reduce the amount of bias that can show up in the process because there's not another human involved.
And the tests can be timed, and the test can be adaptable and dynamic for the device that the patient is using. Whether that's an ipad or a phone or computer. So we use a combination of the digital cognitive assessment tools. And as Dr. Sanders mentioned, some of her own tools as well as some of the more traditional cognitive screening tests.
Treatment Options and Disease-Modifying Therapies
Maria Thomas: I know there's a couple more questions here. We will try to get to them, but I think we should switch gears, Dr. Sanders, and talk more about modifiable risk factors and treatments. So we've discussed a lot about the importance of paying attention to your cognition about getting assessed. And let's say, for example, someone gets assessed, and it turns out that you know their cognition is not within the normal range. Or let's say you've diagnosed them with mci, mci, perhaps. What are the options available to folks? What are the treatment, the state of affairs in treatment today?
Dr Amy Sanders: We? We? Yeah, that's that's a fantastic question. So the the way that I think of sort of how I, the buckets from which I draw upon symptomatic treatment, disease, modifying treatment.
And then sort of what I think of as kind of a contextual treatment, so symptom modifying treatments we have had for decades
in Alzheimer's disease. People might have heard of Aricept, probably the one that is most commonly used, and that's the brand name. The generic name is Donepezil. That medication comes from the class called the
Cholinesterase inhibitors. That's Donepezil, rivastigmine and galantamine, and they work by blocking the action of an enzyme that breaks down an important brain chemical. It has nothing to do with amyloid, nothing to do with Tau.
But it does help brains afflicted by Alzheimer's disease to think better, even though they're not directly affecting the underlying disease pathology.
Starting about 2 years ago, we started getting for the 1st time ever disease modifying treatments.
That's the famous Lecanemab. The brand name is Leqembi, or Donanemab. The brand name is Kisunla. There was a 3rd one, but it has gone the way of the dodo, and is no longer being prescribed.
But these are disease modifying treatments they are. You can think of them as little heat, seeking missiles that get injected into your bloodstream via an IV. They circulate, they get into your brain where they target amyloid protein, that nasty bad Alzheimer amyloid protein that got deposited into amyloid plaques. That's what those monoclonal antibody disease modifying treatments get rid of.
Leqembi reduces the amount of amyloid in the brain Kisunla in the clinical trials could get rid of it.
So that is a big deal.
But even though these are big neuropathological, heavy hitters clinically, this is not a cure.
Do they buy people extra time? Yeah, they probably do.
There are side effects. Not everybody is eligible for these medications. They're powerful medications, but one of the most powerful effects that they are going to have is, they have reinvigorated, given rebirth to interest in drug development.
In the pharmaceutical world, to develop more and better drugs to treat, not just Alzheimer's disease, but other dementias as well. This is the beginning. It's not the beginning of the end, but it may well be the end of the beginning.
Maria Thomas: That was extremely profound. I do want to take an opportunity to mention here that at Sunday health we have a partnership with another company locally that has a center in Fairfax, Virginia, that runs clinical trials for mild cognitive impairment and Alzheimer's disease. They also have an infusion center there where they are administering Leqembi and Kisunla. So if one comes to Sunday health and is seen by Dr. Sanders or one of our other cognitive neurologists, we may end up, depending on what the situation is suggesting one of the 2 drugs. But, as Dr. Sanders said, they're not for everybody.
So, Dr. Sanders, I think it's important to talk a little bit more now about the modifiable risk factors that you've referred to multiple times here. What are they? And what do we know about them?
Modifiable Risk Factors
Dr Amy Sanders: Yes, there are many of them, and probably more than you might think.
Some of them are obvious.
I, like every physician, will tell you. You gotta eat right. You gotta exercise. You gotta sleep well. I make a real effort to tell you why
We tell you those things. And in dementia. We are actually beginning to really establish some causal relationships, I mean, and that's in science and medicine. That's a big deal. We can often say that 2 things are related to one another associated with one another, but it's much more difficult to say that this one leads to that one or the other way around.
We are learning more and more about the powerful nature of the modifiable risk factors.
If you take one action item away from tonight's webinar, please let it be that you will get your hearing checked.
And if problems are found, or if problems have previously been found, you will wear your hearing aids, and please tell all your friends.
Putting hearing aids in every day is like a vitamin for your brain.
Untreated hearing. Loss is one of the most highly impactful of the modifiable risk factors. If we add up all of the modifiable risk factors, according to a major, think tank in in the UK.
We might be able to reduce as much as 40% of the incidence of dementia.
So when somebody says you got to exercise right and eat right and sleep and manage your stress.
There is real benefit to doing that. It's not just your doctor flapping his or her gums.
It really matters. This stuff really matters. It's why I have only had potato chips, not even this many times in the past 2 years.
One of the other modifiable risk factors is the amount of ultra processed food in one's diet.
I have had to give up Coca-cola. Not completely. I still have it. Occasionally we're all a work in progress, and there are certain things I'm not willing to compromise on. And, as it happens, Coca-cola is one of them. But now I have it as a treat. I don't have a 6 pack every day. I have one coke every month.
What seldom is wonderful works for me.
All of many of these things air pollution.
And I'm not just talking smog. I'm talking microscopic particulates that that have been measured in places as diverse as you know, roadsides in in middle America and subway tunnels in New York City.
Just we are. We are multifactorial, multifaceted organisms, and there is more than one way to skin the dementia cat. I can't believe I just use that as a metaphor.
Maria Thomas: On that note I'm going to call out here on this slide. At the bottom is a link to the source of these 14 modifiable risk factors, which is a Uk group called the Lancet. The Lancet is a highly respected publishing organization, and this particular study comes from the Lancet Commission on dementia.
If you look at the study and you can find it by googling it. The Lancet Committee on Dementia. It was the most recent paper was published last July 2024. What you're going to find in there is they're going to talk about the fact that if one takes seriously what Dr. Sanders was just saying about the modifiable risk factors that up to 45% of cases of dementia can be prevented or delayed. And so there really is some research behind this. We're not just saying, Hey, you know, eat right exercise and sleep well, which are also helpful to your brain. But there's a good deal of research behind it. There are other studies as well, but that's 1 of the more recent ones.
Care Delivery Models and Provider Shortage
Maria Thomas: I did want to address one question that's come up in the Q. And A. Here. That's about who's delivering care? And the question was specific to Hopkins locally here, Dr. Sanders, in Baltimore. But the question was about, you know, does one need to see an Md. Or can one see a nurse practitioner, or a nurse?
And I thought I'd take the opportunity to share how we do it. But also, Dr. Sanders, please comment on whatever I'm saying. At Sunday health. Our process is we do leverage nurse practitioners, in part, because people like Dr. Sanders are very difficult to find in the United States. If you don't already know this, there is a dramatic shortage of neurologists in the United States and in an even more significant shortage of cognitive neurologists.
And so if you try to get an appointment in the Dmv. With any of the cognitive neurologists at Inova or Georgetown or Hopkins. It's very likely, unless you know somebody, that you are going to be waiting 6, 7, 8 months to get your 1st appointment. So at Sunday health.
As I mentioned up front, we do do telemedicine. We also have an office, but because we do deliver a lot of our care through telemedicine. It enables us to hire, you know, exceptional neurologists like Dr. Sanders wherever they may be. She happens to be in Connecticut.
And it also enables and because we also have nurse practitioners under the training model of Dr. Sanders and some of our other Mds.
It allows us to get people in more quickly, and all of our the 1st appointment at Sunday health is done by a nurse practitioner, so that full assessment with the digital cognitive assessment and the other tools that we talked about would be with a nurse practitioner. Dr. Sanders helps to develop our training program and works very closely with the nurse practitioners.
But there aren't many people like Dr. Sanders in the United States. And so that is our model. And please Dr. Sanders feel free to add your own color to what I'm saying.
Dr Amy Sanders: Yeah, I mean, I think the shortage of neurologists, the shortage also of geriatricians who are internal medicine physicians who do subspecialty training in the care and feeding of older adults. So there's a terrible shortage there as well in neurology, neurologists historically
Sort of voted with their feet away from practicing cognitive neurology because it was practically impossible to make a living doing it. So most people who had interest in this went into research.
And now, in the clinical world of cognitive neurology. Now we have new tests, and we have new treatments, and it's the most exciting time of my career. But people are now scrambling, because, you know, they're just there aren't very many. Me's out there. And so it's a problem of of having enough cognitive neurologists in particular, it's having a problem of having not enough neurologists more generally, and I would say that
One is probably better served by seeing a nurse practitioner with experience.
Who has therefore developed some expertise in taking care of older adults with cognitive concerns or complaints than somebody who does not have that that interest, that background, that passion, that drive.
You can go into any doctor's office, and they're going to give you the 3 word memory test, and maybe they'll ask you to call it to draw a clock, and then, and it breaks my heart when I when patients come and tell me that this has happened to them, they'll get told. Oh, you have Alzheimer's disease. Here, take this medicine and come see me in a year.
That just isn't good enough.
So I think that the way forward here is really going to be for neurologists and nurse practitioners working in concert, working in tandem with one another, because we each have skills that we can bring to the table to help older adults with cognitive concerns and cognitive worries.
Parkinson's Disease and Related Conditions
Maria Thomas: Thank you, Dr. Sanders. I think we have time for 2 more questions, and so in no particular order. There was a question here. How does all of this relate to people with Parkinson's disease.
Dr Amy Sanders: So another umbrella, a slightly different umbrella. This is the umbrella of neurodegenerative disease. So neurodegenerative disease subdivides itself into sort of movement, prominent conditions and thinking prominent conditions.
Parkinson's disease is more of a movement, predominant condition. Have I seen patients with Parkinson's disease over the course of my career? Sure have I diagnosed patients with Parkinson's disease? A few. But that's not my main sandbox. People with Parkinson's disease are usually seen by movement disorder specialists.
People with most forms of dementia usually come to a cognitive neurologist like me.
However, there is this thing.
PDD. DLB, so PDD. Stands for Parkinson's disease with dementia, and
Most people believe that most people with Parkinson's disease will develop dementia if they live long enough.
But that can take decades, plural decades.
If people develop Parkinson's disease. First, st the motor problem, the tremor, the falling, the shuffling gait, and they developed dementia at least a year after they started having physical symptoms that's classified as Parkinson's disease dementia.
If dementia shows up 1st and eventually, then they develop Parkinsonian signs as well. That gets called dementia with lewy bodies, it's really sort of 2 sides of the same coin, and I'm pretty comfortable treating dementia with lewy bodies as long as it's mostly cognitive and behavioral. Once it gets into the physical dimension of it. Then I really want the assistance of a movement disorder specialist. So Parkinson's disease really is a is a special case because it has flavors of sort of more than one kind of neurology probably feels to the person who has it and their families, especially if it's Parkinson's disease or dementia with lewy bodies where there's both movement problems and thinking and behavior problems feels like more than one disease.
Concussion and Memory Pathology
Maria Thomas: Thank you for that clarification, Dr. Sanders. We have just a couple more minutes, and there's 1 more question I want to take from the Q. And A. Can. Dr. Sanders speak to the impact of a concussion causing dementia and other memory pathology.
Dr Amy Sanders: So yeah, you want to avoid hurting your coconut. There's a new. I don't know if you've seen this new ad campaign, but with the melon as a head, and and protect your melon. It's such a so smart we know that repeated head injuries are not good for the brain. You've probably all heard about the football players and
Chronic traumatic encephalopathy. You can't go to a doctor like me and get that diagnosis. The only way you can get that diagnosis is if a pathologist looks at slides of your brain under the microscope after you're dead.
But that is proof positive that getting your head hit a lot can lead to devastating consequences. So protecting your head is very, very important. Soccer players have been studied about, you know, when they head the ball. You think of football players, but soccer players.
Yes, soccer players, too. So there is a a relationship there. It is not fully explicated and understood. Is it truly causal?
We're not sure. Is there an association? Yeah, there probably is.
Closing Remarks and Contact Information
Maria Thomas: Thank you. There's a couple of questions that I know how to answer. The 1st one is, yes, you. If you registered for this webinar, you will get a a recording sent to you. Christy and Ginger, that's correct. Right?
Kristy Kennedy and Ginger Noce: That's correct.
Maria Thomas: Okay? And the other one was about Dr. Sanders. I mentioned that she lives in Connecticut. She's practicing with us at Sunday health. So that means she's practicing in DC. Maryland, and Virginia, and we do not have a physical office in Connecticut at this time for the person who was asking about Connecticut. We hope to have an office one day or be practicing via Telemedicine in Connecticut and other States as well. But for the moment we're focused on DC. Maryland and Virginia. And if anyone, after listening to Dr. Sanders would like to contact us, this is how you can find us. We have a website, sundayhealth.com, we have a phone number. Our phone number is on the website. So it's easy to find. As I mentioned before, we do take all sorts of insurance and Medicare. You can also email us at Hello, at Sundayhealth.
And the best news yet is we can get folks in usually within 2 weeks. So if you have a concern and you want to see, you know, expert clinician, we are available, and I just want to close here by thanking silver bridges for their partnership for this webinar, and for all that they do, because they provide a lot of help to folks across the nation. And in this region. So thank you, Christy and Ginger.
