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Maria Thomas: Thanks again for joining, everyone. My name is Maria Thomas. We'll go ahead and get started. You've joined a webinar this afternoon that's hosted by Sunday Health, and I am the non-clinical CEO of Sunday Health.
We are a preventative cognitive care clinic, based here in the DC, Maryland, Virginia area. When I say preventative cognitive care, what that means is that we focus exclusively on cognitive care, and specifically with an approach and a care model and a care team that's designed to try to prevent and delay cognitive decline. We operate in DC, Maryland, and Virginia. We offer appointments through telehealth and also in person.
But today, we're not here to specifically talk about the clinical care that Sunday Health provides. We're really here to talk about the important topic of how social connectedness relates to our overall health, our lifespan, and our cognitive health.
And we have two wonderful guests joining us today. Before I introduce them, I do want to just go over a couple of administrative items. First of all, we had a number of folks submit questions in advance. Thank you for those of you who did that. We tried to incorporate answers to those questions into today's presentation. We will be taking questions during the webinar. If you have questions, please look at the very bottom of your screen here. There is a button with a question mark in it that says Q&A underneath of it, if you can find that button now. That's where we want you to go to submit your questions for either Ken or Dr. Doyle.
As I mentioned, we are recording this, and all registrants to the webinar will receive the recording later in the week. What we are not here to talk about today in terms of questions are specific, clinical care questions or specific medical questions. So if you did have specific medical questions, that might be something that you want to make an appointment with Sunday Health about.
Maria Thomas: So with no further ado, I would like to formally introduce our guests today. They are Ken Stern and Dr. Sarah Doyle. Ken Stern is a nationally recognized expert on longevity and aging. He's the founder and chairman of the Longevity Project. He hosts a very popular podcast called Century Lives, and both Century Lives and the Longevity Project were produced in collaboration, or launched in collaboration with the Stanford Center on Longevity. And you can find those links, in the chat.
His most recent book is called Healthy to 100. I'm holding it up, I can see it's a little pixelated, but here it is on the screen. It's called Healthy to 100, How Strong Social Ties Lead to Long Lives. And this is, really the topic of today's conversation. Ken is the CEO of Palisades Media, and also a former CEO of NPR National Public Radio.
And Ken is joined by our own Dr. Sarah Doyle. Dr. Doyle is a board-certified physician and neurologist. She works with us at Sunday Health as a cognitive neurologist. She's also an assistant professor of neurology at the Glen Biggs Institute for Alzheimer's Disease and Neurodegenerative Diseases at the University of Texas Health Center at San Antonio. Dr. Doyle is trained in chemistry, medicine, and public health. She has received her MD from the University of Rochester and she also received a Master of Public Health from the University of Wisconsin. So welcome, Ken and Dr. Doyle, and welcome, everyone.
We're going to kick off with Ken. Ken, your book took us on a really fascinating journey to 5 different countries, and I wondered if you could start us off with what led you to write this book, and where did you go?
Ken Stern: Yeah, so, first of all, thanks, Maria. Nice to be here with you and with Sarah.
So the origin story of this book actually begins in a little town called Presidio, Texas. So, as you mentioned, I host this podcast called Century Lives. And it's a little bit of an unusual podcast. It's a documentary podcast. We have seasons built around specific issues. Our next… our next season, just for instance, is around housing a popula… how do you house a growing population of older Americans? A few years ago, we did a season on what you might call the outliers. So, we were looking at the research of a guy named Raj Chetty at Harvard, who had done a series of studies of plotting county-level income versus county-level life expectancy. And, essentially showing the world that wealth equals health in some… in most cases. In fact, almost in a… sadly, almost in a mathematical formula. But there are some outliers, and we were interested in what… where were the places in the country that overperformed, as you might expect, compared to their income. So we went to a number of places. There weren't a lot of outliers, actually.
We went to… we identified a few, and wherever we went, started in Presidio County, Texas. This is a very poor county on the border with Mexico. One of the poorest counties in Texas, and one of the 10 longest-lived counties in the country. And when we started the investigation, we didn't really know what we'd find. We didn't know what we'd find about good healthcare, or about exercise or nutrition. It turned out wherever we went, the story was about social connection.
And, the effort in those communities to find ways that keep people socially connected, and giving people in the second half of life, meaning and purpose. So, in Presidio County, it was all about intergenerational communities, often three or four generations of the same family living together on the same block in Co-op City in the Bronx. It was sort of about housing. People in one of the most expensive cities in the world, Co-op City is the largest provider of affordable workforce housing, so people moved there and stayed. They stayed for generations. And that created community and opportunities for people to really be connected with one another. And it surprised us, so that got us thinking about the importance of social connection to health. And then that led me down this rather long path that said, you know, The U.S. is obviously being challenged by this loneliness crisis. We've been pulling apart for 40 years. Technology has gotten in the way of human connection.
And that has led to the American life expectancy disparity, where we live fewer years than every other developed country, economically developed country in the world. And I want to know why some of those countries, which face the same technology challenges, the same sort of urbanization, transitory lifestyles that we face here in the U.S, why can people in Singapore and Tokyo and Barcelona flourish from a health and life expectancy perspective when we couldn't, and that's what the book led me to. Five countries that are… it really shouldn't be world leaders in life expectancy, but are. Japan, South Korea, Singapore, Spain, and Italy. And that's the… that's the genesis of the book and the roadmap of the book.
Maria Thomas: Thank you, Ken, for sharing that, and it's really powerful to hear you say that the U.S. has fallen behind in terms of developing… in terms of developed countries and life expectancy, and we'll get into that a little bit more. But actually, that does lead me to the next question regarding measuring social connectedness. You talk about life expectancy, but when we think about social connectedness, you know, for other health measures, we have numbers, or biomarkers, or things that we can sort of singularly hone in on. How should we think about measuring social connectedness?
Ken Stern: Yeah, so, not as well, you know, in the world of advanced science that you all live in. Not as well as that, but there are ways of… measuring, loneliness and social connections. So, often measures of loneliness are self-reported diagnosis of, are you feeling lonely? How often do you feel lonely? But there's also, I think other measures, like how much time do you spend with friends? Young people now spend about an hour less with friends every day than my generation did.
How many… friends do you have? How many friends can you call on in an extensive emergency? Now, those are not great, I think, sort of great scientific markers, but they've been tracked for decades, and what you can see is, very clearly the decline in the number of people who can say, I have 6 or more friends, and a huge increase among people who say they have no friends. A doubling or tripling that over the course of 15 or 20 years. And those, to me, are sort of… you know, bonfires, that there's an emergency going on with respect to loneliness and social connection in this country.
Maria Thomas: Yeah, that's re… that's really stunning, to hear, and when you… when you talk about people who say they have no friends. Dr. Doyle, I'd like to bring you into the discussion, and on the same theme, from a clinical perspective, maybe you could just talk a little bit about social health and measuring… measurements of social health versus traditional health.
Dr. Sara Doyle: Yeah, absolutely. Good afternoon, everyone. So… social health, as Ken said, there's not, you know, an objective… perfect objective measurement of it, and a lot of the studies rely on self-report because, you know, the feeling of loneliness is a subjective one. But there are many many observational studies, where we follow people over time and, see how they do, basically. And it's from these studies that we have found a number of modifiable risk factors, quote-unquote. And that means things that you could potentially treat. And these are things that, if you have more or less of them, you may… you're more likely to get dementia. And so, for example, in these observational studies where we're following people over time, people who report more hearing loss are more likely to get dementia. People who have lower levels of physical activity are more likely to get dementia. Now, that does not mean we don't always know exactly why, and we can get into more of that later, but one of these factors is social connectedness, and
We measure that through, in these studies, these, you know, rigorous observational studies, they measure it through asking people, you know, how often do you feel lonely, or how many social connections do you have per week? And they might, you know, define that a little bit differently, but it's a fairly standard set of questions that, studies here in the U.S. and internationally use to measure how connected people are socially. And what many tri… or what many studies have found is that the higher levels of loneliness, or the lower levels of social connectedness, the more likely it is that somebody later on will develop cognitive impairment or dementia.
And so there's now more research coming, or, you know, research… looking at, you know, why is that the case? And I'm sure we can all hypothesize why, you know, it kind of… on a gut level, it kind of makes sense. But in terms of you know, whether it's a direct effect or an indirect effect, we don't fully know, but I think it's something that we as doctors and neurologists should be focusing more on, or incorporating it as a part of our care plans as we're thinking about, healthy cognitive aging and brain health.
Maria Thomas: Thank you. One of the so-called modifiable risk factors that was on the slide that you were presenting there had to do with hearing, and we did have a question prior to, that was submitted prior, and the question was about, hearing loss, and the specific question was, is there a connection between hearing loss and dementia?
Dr. Sara Doyle: Yeah, that's a great question, and I think this has gotten a lot of attention recently, in a good way. So the short answer is that… is that yes, many studies find that there is the… if you have hearing loss, you're more likely to have cognitive impairment later on in your life. The complicated answer is that we don't yet know what to do about it.
There was a trial that, called the ACHIEVE trial that came out, in 2023, and this was a trial that basically said, okay, we're gonna give people hearing aids and see how they do. And at 3 years, they couldn't measure a difference between, the people who got hearing aids and the people who didn't, in terms of their cognitive performance, so they… they said, well, we can't at this point say that hearing aids make a big difference, but… you know what, maybe we didn't give them hearing aids for long enough. And so that trial was actually extended for another 3 years, and they will… those researchers will continue to do cognitive assessments regularly on all the participants to see if, if it just takes longer to measure a difference. So, I think that's exciting.
And I would also put in the caveat that hearing loss or, you know, having hearing aids to improve your hearing there's other reasons that that can improve your life, right? Even if it doesn't directly, measurably affect your cognition, it makes it more likely that you're gonna spend more time with other people, improves your quality of life, you know, so… I think there's more to it than just dementia prevention, even though that's exciting for everyone, but, certainly this is an area of active research right now.
Maria Thomas: Yes, as you said earlier, sometimes things make sense on a gut level, and it seems to make sense to me on a gut level as a non-clinician, that if one is having trouble hearing, it's likely that one will retreat somewhat from a social situation, and so that does make sense. Dr. Doyle, I do want to come back to the modifiable risk factors, because they play such a huge role, but I want to let Ken jump in for a second.
Maria Thomas: Because there were some other questions related to this that came in early, and Ken, one of the questions that was submitted was, and I'm going to read it verbatim, was, I don't like growing old. I need to accept this, but are there ways to enjoy it? And another one that was related to this was, what if one is not a joiner, or is introverted? So I wonder if you might comment on those two, those two items, and maybe… maybe share some anecdotes that you saw from your travels that relate…
Ken Stern: Yeah, so, those are two good questions, and sort of two hard questions, so let's talk about the growing old. Which is something a lot of people, and I'll say myself included, fear. I think that's actually a social norm in the U.S. that is actually a little different in other countries. In other countries, people… I think countries that have less of an ageist profile tend to honor the act of growing old more, and so people have different relationship with growing old. But even in the US, I would say, one of the things that, has always struck me is what's called the U-curve of happiness.
So, social scientists measure… happiness, people self-report happiness, and tends to be higher when you're young, and higher when you're old. So it's the U-curve. It starts high, and it dips down in the middle of life when you're, you might be squeezed in the sandwich generation. And then tends to go up when you're older. And that's maybe not because, older age is necessarily a more joyous time, but because people who have, can handle stress better, and know the ups and downs of life, and can handle it on a more even keel. So I tend to think, you know, while we tend to fear some aspects of old age, I don't think it's necessarily a time of unhappiness, at least compared to other ages. Some of the things I saw in other countries, you know, I think the what people feared, in the second half of life was being useless, not having a purpose, being left behind. And the thing that gave them, often found, give them… giving them joy was… getting re-involved in community life. That meant, for a lot of people going back to work, my book starts off with the story, a story of an 80-year-old woman, in a small town outside of Fukuoka in Japan, who had actually gone to work for the first time when she was 85.
Her kids had left her… kids had grown up, moved away with the grandchildren. Her husband was fully retired, they were… not entirely comfortable by themselves together in the home, and, you know, she decided that she saw her friends going back to work, and so she went to work. And she loved it. She worked 3 hours a day. And it brought joy and purpose to her life. And I heard that, not just about work, but learning often, you know, that these activities that we associate with earlier parts of life still brought purpose and joy in the second half of life.
And now, Maria, I've now completely forgotten the second question.
Maria Thomas: The second question was about, what if one is not a joiner?
Ken Stern: Oh, yeah, yeah, yeah. That's a great question. So this is sort of the introvert-extrovert question, that comes up in almost every conversation, and I was actually interviewed for a story on that in the New York Times, someone wants to read the article by Dana Smith in the New York Times from about 2 weeks ago, will be a better answer than I can give here. But, it's a great question, and the way I think about it is, we're a lot lonelier than we used to be as a country. It's not because we're a lot more introverted than we used to be is because the systems that existed to bring people together have atrophied and decayed. So, you know, there are things like churches and unions and sewing circles and reading clubs and PTAs, they've all atrophied.
And those things were not, a reflection of people being joiners or not joiners. They were places that naturally brought people together. I mean, the research on this is usually takes about 50 hours excuse me, 50 hours to be near someone, to become a friend, 200 hours to be a good friend. It's not so… becoming friends is really not going out and being the life of the party, and buying people drinks, drink, you know, rounds of drinks. It's about putting yourself in situations where you're naturally associated with people of common interests. That could be work, that could be at school, that could be volunteering, that could be in intergenerational relationships, it could be, you know, all sorts of things that have nothing to do with your personality. It's about, being in places that naturally bring you into contact with other people. And that's what we should look for, is things that bring us purpose and brings us into community with other people without having to be someone that we're not.
Maria Thomas: Thank you for that. Dr. Doyle, we're going to go back to hearing for just a moment, because there's a question submitted that, basically a very good question. Did you measure the use of hearing aids, or just aids or just giving aids to people, noting that lots of people don't use their hearing aids, even if they need them. So, differentiating between testing for the need and testing for the use.
Dr. Sara Doyle: That is a fabulous question, I agree. I would actually have to go back and read the trial to see if they controlled for that at all, because they, you know, gave people hearing aids, but I don't know… you're right, and this is why, there is a branch of research called dissemination and implementation that's basically like, yeah, you can do these trials, you know, people can sit in their ivory towers or wherever these trials are designed and say, this is a really good idea, but practically on the ground it makes me think of, you know, using a CPAP for sleep apnea, which people in the audience might be familiar with. There's a lot of time… I hear this in the clinic all the time, of, I put it on at night, and then sometime in the middle of the night, it comes off.
And so there's a, that's… that's a fabulous question. I don't know, but, we, you know, we can go look, and if they didn't do that, I think that would be an important component of any sort of trial design in the future, to be like, well, maybe we weren't actually exposing people to any degree, meaningful degree, of hearing aid use, because people just don't like to wear them.
Maria Thomas: Right. Right, no, good point.
Maria Thomas: And if I may, you know, use this as a jumping-off point to talk a little bit about, the study that came out during the summer called the U.S. Pointer Study. This was a study that was published in late July by the, and funded by the Alzheimer's Association. And the reason I'm bringing that up, we're talking today about social… the importance of social connections to our overall health, to our longevity, and to our cognitive health. And you heard Dr. Doyle mention before that there are actually 14 modifiable risk factors, one of which is socialization. But, Dr. Doyle, I think it would be interesting just to spend a moment on the pointer trial, and the reason I'm bringing it up here, as it relates to the hearing aids question, is that there was a very interesting component of it that involved, kind of these, like, motivational coaching or accountability, and maybe you could touch on that.
Dr. Sara Doyle: Yeah, absolutely, good question. So, just to back up for a moment, and maybe we can put the slide up just to, remind people of it, or have a graphic to go with it, but, so, there's 14 modifiable risk factors, and to give people a sense of where those come from, these are from observational studies where researchers follow people over time, sometimes decades, and they just gather information on their health and see how they do later. And so that's where, you know, they can find, oh, people who have more or less of any of these things have a greater or lesser propensity to get… to have cognitive decline or dementia later on. So that's where these come from. Now the research to definitively say that treating any of these things, like hearing loss, or like, you know, any one of these other things, diabetes, treating these things, research to definitively say that treating those delay or prevent dementia is… catching up.
There have been some trials on blood pressure that say, yes, if you treat your blood pressure towards the 120 over 80 goal, you know, in the following decade, you're less likely to get dementia. There's other trials that are coming out to get at some of these things. So the Pointer trial, was a two-year trial that, included physical… that randomized people, so we're kind of comparing apples to apples here, randomized people to a program where they did physical exercise, and they intensely monitored different health factors. They gave them education on nutrition. They did some cognitive brain exercises, too.
So one group did this, like, specific program that involved meeting in small groups and motivational interviewing, so that people could set goals for what they wanted to do, and they regularly met with them. The other group that they compared it to, they just gave that group of people education and said, these are things that are helpful for your brain and cognition over time. You know, you figure out if you want to do this or not in your life. And, the researchers measured their cognitive abilities in both groups regularly for 2 years. And here's the thing. Both groups improved.
But the intervention group improved more, so the group that did the full program with everyone else, they improved more, than the people who just got the, you know, information that these things are important. And it's tricky to measure, but I'd venture to say that the social aspect of the program that they designed made a big difference. And, you know, as we talked about earlier, this may be something inherent to connecting with other people, you know, as social primates, maybe that's just really, really good for our brains.
Or it may be when you're with other people, you're more likely to show up to the strength training class, or you're more likely to, you know, eat the… vegetables that you're supposed to, or you're more likely to learn how to cook the vegetables that you're supposed to be eating. You know, those… we can all, again, we could sit here and just armchair about it for a while, but I do think that, if loneliness or, you know, lack of social connectedness is a risk factor for dementia, the interventions that we build to prevent dementia whether these are, you know, direct for the individual patient, or on the population level, they need to include and prioritize a social aspect. And I think, Ken, I loved hearing all the examples from other countries that have made it a national priority to build this population-level infrastructure.
Maria Thomas: Yeah, Ken, I think it would be great, maybe you could share some of the examples that you saw in Korea, or Japan, or the other countries.
Ken Stern: Yeah, so, the book is structured so I talk about different aspects of social… of how… so, the one thing that connected… the thing that connected up all these countries, much more than anything else, was the notion that social connection was a… community effort, that there needed to be a social health infrastructure created. And in Japan, that was often work, and Korea was around lifelong learning the place that was most… and it speaks sort of the nature of the place. I think the place that was most… aggressive and forward-looking was Singapore, which sort of made it a whole-of-nation effort to create opportunities for people in the second half of life to continue to work. They gave, essentially, free education credits for everyone. They created courses for it.
They turned the national organization that was responsible for assigning older people to nursing homes into an organization that was designed to help people stay socially connected. And I spent time in something called the Queenstown Health District, which was, it's about… it's an area of about 100,000, which essentially is a testbed for how to organize the city. And in… you know, in the U.S, when we talk about health districts, we really talk about unhealthy districts, a place with a lot of hospitals and doctors. There, they meant this is a place where we're going to try to keep everyone healthy, so they have to spend less time with hospitals and doctors. So, that's about… that got into how they organized the housing, so that it was all intergenerational, it was a turning… senior centers, just centers for all ages. It was about creating micro-jobs for older people. It was all about, sort of, that notion of social connection, intergenerational relationships, and making sure no one felt alone, really, and isolated ever. So I,
And sometimes it was the… one of the most interesting parts of it was when it was sort of the old taking care of the old. So, I went, I mentioned micro-jobs. So, the effort to create part-time work for older workers who want to go back to work and stay involved and engaged. And one of them was essentially a Meals on Wheels project, where the older folks were the last mile delivery to other older folks who were, so, I went out with them. The older folks would come in, they'd get their selections of meals, they'd… we went out to deliver it to essentially shut-in elders.
And they were their… they were not only delivering meals, but they were their lifeline. They checked in with each of them, they were their social connections, their friends, they made sure that they didn't eat anything else. They were, you know, they were… they were just, people working, but they were also, in effect, their social workers, and that gave a sense of purpose great purpose to the older workers, and a sense of social connection. So it was really building that whole ecosystem of social connection as, you know, which was really impressive, and I think a model for the rest of the world.
Maria Thomas: And Ken, these are such great examples. Did you, observe or learn, you know, what was the… were these coming from sort of a policy, top-down type initiative, or are they ground up, a little bit of both? How are they… how did change actually happen? It's such that, you know, what can we learn as a society from these.
Ken Stern: Yeah, so it's both. But I actually think… so Singapore's an interesting example, but it's also a very specific example. It's a very… it's a small country, a lot of, a lot… the government is… controls a lot of social organizations. They control all the housing, for instance, which makes a big difference. And they have a long history of large-scale governmental interventions in how we organize society, and that's a little different than many other countries. So that was more of a top-down driven one. The other places were much more, reflect the notion that politics is downstream of culture.
And, before political change and economic change was made, you had to change the notion of of how people viewed the rules of the second half of life. So in Japan, to return to that, Japan used to have a very strong upper-out retirement system until not, you know, just a couple decades ago. You hit 60-ish, and you had to retire by law. But over the last couple decades, people began to, they actually created a philosophy called Ikigai, which they associated the activities of, of work, with happiness, with health.
And the… the culture began to change, that people began to associate working in the second half of life with meaning and good health. So, like, 80% of the older workers in Japan say they work not for the paycheck, but for what it brings to them individually, for their… for their sense of purpose, for a sense of value, and for health. And once that cultural change had happened, you know, other things began to fall in line. Companies began to change their practices, government began to give incentives to companies to employ older workers. But it had to start with the change in the culture. And I think work's a good example because you see all the time countries trying to encourage people to work longer as a matter of sort of pension stability, in a world in which we have fewer younger workers and more pensioners. They want to keep people working. And what they do to do that is they change the pension rules. They say, you are eligible later for your pension.
People hate that, because they're telling them they need to work. No one wants to be told they need to work. In France, they go out and they, you know, they burn garbage trucks when that happens. In Japan, they don't burn garbage trucks because the impetus for change came the other way around, and that's, you know. That's what drives effective change when it's cultural change, not policy change.
Maria Thomas: Speaking of cultural change, one of the things that we're trying to elevate at Sunday Health is the idea that one should get a full cognitive, a thorough cognitive assessment, early. And that if you're interested in preventing cognitive decline, the key is to start early. And sometimes we say, you know, in this country, when we all turn 50, we somehow know that we're supposed to schedule a colonoscopy. And if we're women, we know that we should start getting regular mammograms and men PSA exams, but somehow that thorough cognitive assessment, that brain test, doesn't make the list.
And so, when we think about changing attitudes and changing cultural approaches, there's still a little bit of stigma… stigma, excuse me, associated with dementia. So, Dr. Doyle, I'm coming to you to maybe say, as we think about this topic, we've been talking about century-long lives and socialization, but maybe just let's take a step back and go to the core of at what age should someone get a thorough cognitive assessment?
Dr. Sara Doyle: That's a good question, and I think, you know, those are apt comparisons of, you know, the colonoscopy or the, you know, mammograms, and saying, okay, early detection means that you can treat it better, and perhaps, if I was just gonna opine for a second, I think we've taken a rather futile, perspective as… as… as healthcare providers, as society, as neurologists, towards dementia, as that's just an inevitability of older age, and therefore, like, why detect it early if there's nothing that you can really do about it?
But I think that's changing because of research that's coming out, and so… I don't… I wouldn't be surprised if the U.S. Preventive Services Task Force, I know they made a comment on this in the last 5 years, it might have been early 2021 or so, you know, saying, you know, we don't really necessarily recommend a cognitive screening at any point, but part of that recommendation comes from, you know, what would we do about it? And that evidence is rapidly changing. So I think, you know, a cognitive assessment, a thorough cognitive assessment is helpful to see where your cognition is right now. Like, by itself, it doesn't tell you what's driving that change. By itself, it doesn't tell you whether or how fast those changes are going to progress, so…
I think that's a question I ask, or I answer for a lot of people in clinic, but… you know, if you do a cognitive assessment at age 50 or 60, and maybe we will get clear guidance on a particular age, but that kind of feels right, you know? You should always do it with a trained clinician, so that you can they can help you develop a personalized plan to say, okay, here's where you're at, and here are things that you individually could, you know, focus on, or address, or dial up, dial down, to really proactively take care of your brain health and preserve your cognition for as long as possible. Or, you know, if you do a thorough assessment and there are deficits, they can really look through your life and say, okay, what do we think is driving this? It may be something like Alzheimer's disease. It may be something else. It may be something that's completely… treatable, like a lack of sleep, or depression, or… you know, there's a number of other things. Certain medications can really affect how your, you know, how clear your thinking is. And so,
I think a thorough cognitive assessment as a baseline is a good idea for many people, but it should always just, you know, it should never be done in isolation. It should always be done with somebody who can help you interpret what that means, and then what you're going to, you know, a screening or a baseline assessment should never just be an end in itself. It should always be, you know, looking towards some sort of action plan, so…
Maria Thomas: Yes, yes, indeed.
Dr. Sara Doyle: I hope that answered your question. I think. We're a little bit ahead of the evidence, but sometimes it takes, you know, the… That's the exciting part.
Maria Thomas: I think what I was trying to tie together, and you did answer it, Dr. Doyle, is this notion that in some of these countries that Ken had visited, there's a cultural approach that's different to older people and to aging, and I was just trying to tie that to how we, as a society in the United States, approach dementia, not just with kind of the… oftentimes not wanting to talk about it, but also, you know, how we think about memory care where people may be living. Ken, I know in conversations that we've had, you've talked about some of the places that you've visited in the United States, not necessarily for people who have cognitive issues, but just people who are over a certain age, and sort of contrasting examples. Maybe you want to touch on that for a moment. I think that's an interesting, you know, comparison between the place that you visited in Florida and the place that you visited in Maine.
Ken Stern: Yeah, so this comes back to, my podcast, Century Lives, as I think I may have mentioned, the next season is on housing, so… we've been… a very sort of challenging subject about, how do you house a population of people over the age of 65? That would be some 80 million by mid-century. So we looked at a lot of different models, and in one episode, we did, we visited Florida, we visited, a 55-plus community in Florida which is a uniquely American housing solution. There's no other place in the world that has lots and lots of… in the US, I think there are about 4 million people over the age of 55 who live in these retirement communities. And we visited Latitudes Margaritaville, which is a brand of the Jimmy Buffett Company, which is a… in this particular place, a particularly brand new place in in Panama City, Florida, which is, you know, people… only people over the age of 55 have lived there, with some slight modification, variations, but that's basically the rule. No children.
single generation. A place, you know, I think the attraction is this is a place where older people can feel… can feel valued because of the center of the operation. And that's sort of the history of those places, which was to create places where older people wouldn't be shunted aside. They'd be, forever young, which was actually the motto of the first 55-plus community called Youngtown.
And then we did a compare and contrast with a place in Maine called Gorham House in Gorham, Maine, which is a nursing home and preschool. So you walk in the door to Gorham House and, the first thing you see is a preschool with kids aged 3 and 4 who are there every day, or 5 days a week and about 150, nursing home residents. And of course, you see the incredible joy that the younger kids, the meaning and purpose and joy that the younger kids bring to the older residents, who otherwise would be, I think, isolated and you know, and nursing homes, as everyone knows, can often be very hard and challenging places. But those kids sort of brought an accent to it, a joy for the older people. But the interesting thing, Maria that was the most interesting thing about that particular intergenerational community was not that it brought joy to the older residents. You kind of expect it, you can see that, you can feel that.
But the preschool director told me a story as I was about to leave that, the elementary school teachers in Gorham, in the city of Gorham, the town of Gorham, have told her that the kids who come for that preschool are the empathetic ones in the elementary school kid… in the elementary school. When a kid in a wheelchair shows up, most of the kids don't know how to deal with that difference, and these kids who come through that preschool are immediately empathetic. They recognize the differences. They're not scared of differences. And that's sort of, I thought, you know, it's a jigsaw piece that fits together, that we… often fail to recognize the value that those relationships bring, not only to older folks, but to the kids themselves.
Maria Thomas: Yeah, absolutely, that's a wonderful contrast.
Maria Thomas: We have a couple questions in the question and answer area. I'm going to start with one that either of you could answer, or we may have to do some additional research. The question is, are dementia rates in places that Ken Stern studied, lower than in the U.S. and other Western countries? I don't know if you know that, Ken, or if you specifically looked at dementia and cognitive decline.
Ken Stern: What a fantastic question, I wish I knew the answer.
Maria Thomas: That's something we can follow up on, unless, Dr. Doyle, you happen to know the answer off the top of your head.
Dr. Sara Doyle: I don't. Off the top of my head, no. I know this is hard to measure, it gets back to just, like, study design, and where do we find these data? You know, how do we track people? I think there was big headlines a couple years ago that dementia was on the decline in the United States, and I assume other countries track with that, or especially the countries that Ken was visiting. I know that's sometimes a little bit controversial, because, you know, the statisticians will go in and pick apart, you know, how they actually got to that number, but, I think… it's helpful to say, you know, maybe the rates are on decline, but there is a big population that's getting older, so even if there's fewer, you know, and if it's 1 in 10 people rather than 2 in 10 people, there's still just a lot more people that are getting older, and age is one of the primary you know, risk factors, not a modifiable one, unfortunately. That, for cognitive decline, and so as we're just… we have a big bolus of people getting older, that this is really a public health issue for this century.
Maria Thomas: Yes, indeed. And, you know, Dr. Doyle, it occurs to me that we keep talking about dementia using the umbrella term, and obviously there are different types of dementia, Alzheimer's being the largest type but, correct me if I'm wrong, Dr. Doyle, is also mild cognitive impairment, and to the question, you know, the question was about, is there a greater incidence or a lower incidence of dementia in these other countries? I think one thing we know in the United States is that the there are millions of older adults living with mild cognitive impairment, many of whom are not diagnosed with MCI. Is that… is that… am I correct, Dr. Doyle?
Dr. Sara Doyle: Yeah, I think so. Again, it's hard exactly to measure, but I think because there is the stigma, you know, stigma in terms of seeking out care because symptoms might be unrecognized, or because certain symptoms might be normalized as, you know, normal aging, people might not be seeking out care, or might not be fully transparent about their symptoms. You know, I think it's hard to measure, but I would venture to say that there are many… many people living with dementia, many more living with mild cognitive impairment, and I think it's a big opportunity to bring the I think there's a huge number of people who, would benefit from… from knowing that there's a lot of different factors that have… go into your cognition. Many of them are in your locus of control and could really help you maintain your quality of life and independence for a long, much longer period of time.
Maria Thomas: Yes, indeed. Go ahead, Ken, yep.
Ken Stern: The one thing I would offer, I don't know the answer to the question. I'll stick with that. I still don't know the answer to the question that was asked. It's a good one. But, the numbers of… it doesn't sort of speak to the sort of the rates, but the number of people with dementia in places like Japan are going to be, as a percentage of the population, going to be higher. That's just because they're super aged society, and the correlation between Alzheimer's and aging. So, in Japan, they're… 10% of the population is over 80, you know, and up from there, and that's many times what our percentage of population over 80… so they… they are trying to deal… I visited a dementia center in, in Toyama, where they're just trying to plan for a society in which just because of the aging of the society, which is going to continue, they're going to have to… deal with, larger numbers of people with cognitive decline. And some of that is around the science of trying to prevent it, but it's also around how then do you normalize, to a certain extent cognitive decline, and help people who have cognitive decline cope with the issues of life, because they're not going to have the space or the resources to, to do cognitive care for everyone. So that's sort of the one thing I learned on that subject that I thought was kind of fascinating.
Maria Thomas: Thank you. We have a question in the Q&A, and if anyone else has questions, please feel free to submit them in the Q&A using the Q&A button at the bottom of your screen. The question is basically more or less about blood-based biomarkers, Dr. Doyle. And I know, this is a kind of a specific question, but I think it's worth touching on the, the exciting news in the arena in general of what are blood-based biomarkers for… how are they used in the detection of, proteins in the blood, and why are they important as it relates to starting early to understand your cognitive.
Dr. Sara Doyle: It's a really good question, and again, this is an active area of research, so whatever we talk about today might… there might be more answers, you know, next month or next year, but I guess briefly, the blood-based biomarkers, are looks for a particular protein in your blood, and the level of that protein, if it's above a certain level, correlates with finding Alzheimer's plaques in your brain.
And so, in May of this year, the FDA approved the use of this particular blood test, for… use in people who have mild cognitive impairment, and saying, okay, if someone's got mild cognitive impairment, and you do this test, and it's above this level, you know, we can diagnose them with, you know, cognitive impairment due to Alzheimer's disease. And so, this test is used… this helps diagnose one of the etiologies of cognitive impairment, and one etiology could be Alzheimer's disease. It helps to diagnose it, because before you… before this test came out, the two… methods, or the two ways that we could diagnose Alzheimer's disease, biologically speaking, would be a spinal tap, which doesn't sound appealing to a lot of people, or a really expensive PET scan, which the tracer would bind to the to one of the Alzheimer's proteins in your brain, and if your brain lights up with it, then you say, okay, those plaques are present. And,
you know, you've got the Alzheimer's pathology on your brain, and then in combination with your cognitive testing, we could say you have Alzheimer's disease, so… I think a big headline from this is that a single blood test does not diagnose you with the disease, and so I think if you're seeking out this blood test, you should always be under the care of a neurologist to help you interpret what that means. It is not yet… we don't fully understand it yet for use in people who aren't having any symptoms, so… at this point, I wouldn't recommend people who are you know, feeling like themselves, going out and getting it, because we don't necessarily know… this is, you know the first… the first task to complete was how do we use this in people who are having symptoms? And now there… there's a lot of observational studies, you know, where they're…
coalescing their data to… to be able to possibly say, okay, if you don't have symptoms, you could get this blood test to know whether you're starting to develop the Alzheimer's pathology, and that could potentially have treatment implications. Currently there is a trial going on, so I'm sure many people in the audience have heard about the anti-amyloid therapy. Lecanemab or donanemab are the two you know, antibodies out there that go in and remove the Alzheimer's plaque. Currently, this is just, approved for people who have cognitive impairment already, so either mild cognitive impairment or mild dementia.
There is a trial going on now called the AHEAD trial, and that is giving these drugs, I forget which one, actually, off the top of my head, I think it's lecanemab, to people who have biologic Alzheimer's, and by that I mean they have evidence of Alzheimer's plaques in their brain, but they do not yet have symptoms, so they're much younger, they're maybe in their 40s or 50s, and they're following these people to see if that delays or prevents entirely them developing any cognitive symptoms. The results from that trial, unfortunately, are not due out until 2030, so it'll still be a while before we know.
But just to share that information with… with folks that this is a, you know, like I said, this is, an active area of research, but currently the biomarkers are available for people who have… are available and reliable for people who are already having cognitive symptoms. It helps to diagnose one of the possible causes of cognitive impairment. And, you know, doing… getting these tested and having a neurologist to interpret them with you is… is… the safest way to go, I think.
Maria Thomas: Yes, thank you.
Maria Thomas: Well, as we're approaching the end of the hour, I'd like to maybe ask each of you for your takeaways, if you will. You know, we've emphasized a few things during the course of this conversation, including the importance of hearing aids if you need them, the importance of starting early on getting your cognition checked and establishing a baseline. Ken has given us numerous examples of the importance of social connectedness and how to maybe think about it, but Ken, perhaps I can start with you. You've seen all of these examples from 5 countries around the world. What, what have you learned? What are you adopting in your own life, as far as, social connections?
Ken Stern: Oh, well, oh. I think for me, so a couple things. it is really… I think the biggest change has been sort of reframing how I think of the next 20.
Maria Thomas: The next 20 years, that is.
Ken Stern: the next 20 years, right. You know, I think we're used to… over sort of a century, we've adopted the notion that somewhere around 60 or 65, it's okay to start thinking about winding down, sometimes people call it the decline narrative. In between my travels in Asia and my travels for my travels in Europe for this book, I was back home trying to remind my family of who I was, and my wife and I went to a wedding, a family friend, and, we got assigned to to, the last table 23, it's a device in the book. I write a lot about Table 23. There were 23 tables, and we were in the 23rd table, which was actually in a different level than the other 22 tables, because there was only room for 22. We were the old folks. Everyone, we were assigned together, because we were… we knew some of them, but not all of them were assigned, because we're all roughly the same age. And the, sort of the people at our table who were drove the table conversation with the people who just retired.
And it was striking to me that we were sitting there, like, the other 22 tables, you know, they were doing things at weddings, they were talking about the big plans, the new jobs, the new homes, the new lives people were forging together, the big trips that were coming. And this table was talking about things that were… they were winding down. And I kept thinking, you know, everyone at this table with some luck should have at least 20 good years in front of them. They should be attract… they should be… we should be approaching them with the same purpose, intent, and idea of contributing to family and communities as we did the 20 years before. And that's not the culture we have, that's the culture we need to create, especially as the society gets older, and especially as all of us wish for more social connection, more meaning, and better health in our later years. So that's, and that ties in, really, with everything that you all were talking about, around social engagement, about cognitive health because there's a connection between… there's a strong connection between social connection, physical health but even a clearer one between social connection and cognitive health. And, there's research on it, but there's also, and Sarah kept talking about it, we know in our guts that it's true. And, you know, that's really what I came away from this trip, and I hope to share with the people on this, call, and, those who read my book.
Maria Thomas: Thank you, Ken. And… and Dr. Doyle, any, takeaways… takeaways from your side?
Dr. Sara Doyle: Yeah, and I think just to… to… springboard off of what Ken was saying, I think this comes up, you know, I've been talking very abstractly with the research and things here, but this comes up in the clinic all the time. You know, I… the loss of social connectedness and then subsequent cognitive decline is a story I hear a lot, and there's a number of reasons why, you know, to be socially less engaged, like retiring from work, or moving to a new city to be near your kids, or even, you know having a physical limitation, you know, whether you had a major surgery, or you've just, you know, you're less… physically active than you were before.
And so, you know, you hear the story of a major life change like this, people aren't as socially or cognitively active, and then they feel like their cognition's not as sharp. And… this isn't to say that I don't… that people shouldn't retire, you know? It's… it's good to transition to less work, or not be moved to be closer with your kids, or that, you know, if your physical ability changes, you're… you'll inevitably be alone, but… I think that with these common life changes, we should be deliberately thinking about our social connections as we make those transitions because this seems to be really important for our cognitive health, and as, you know, as doctors, as neurologists, like, this is something that we should be talking to our patients about in the same way that we talk to them about blood pressure control or a healthy diet, because it's equally as important, at least from a cognitive perspective, and, you know, from a general life perspective, maybe even more so. And then… as a society, and I love what Ken said about, you know politics is downstream from culture, and really, within ourselves first, and then maybe in our small groups and in our bigger groups, there's kind of changing the expectation of what our, you know the last third of our lives really look like, our expectations for ourselves, because then the infrastructure comes from there, the policy comes from there, you know, having a… a place where I can refer people to and say, okay, we're developing this plan together, but then where are we going to go? And having that be front of mind, rather than, like, I don't know, it's important, and I'm not really sure what to do. So, I think my main takeaway from… or if there's anything that I'm thinking about a lot, it's just that… this is really important for, like, us to think about as individuals, but then also to think about in our networks and in our communities.
Closing Remarks
Maria Thomas: Thank you. That's a really beautiful note to wrap up on, and I want to thank both of you for joining us today, and really want to thank everyone who joined. I know there were some additional questions in the Q&A. They were very specific medical questions. We can potentially follow up with a couple of you directly, but also anyone participating today should feel free to reach out to Sunday Health if you're interested in the work we do, and interested in the type of approach that Dr. Doyle was just suggesting. I want to thank Ken and encourage folks to take a look at his book, which I'm trying to show on the screen, but it's not working out very well.
Ken Stern: There you go.
Maria Thomas: Oh, yeah, healthy to 100.
Ken Stern: Oddly, I happen to have a copy of my book hanging.
Maria Thomas: That's amazing. The book is widely available. It was literally just published two weeks ago, so it truly is hot off the press, and it's very engaging with a lot of anecdotes, a lot more anecdotes than we were able to share here. Also, right after we conclude this, you are going to receive… those of you who are participating will receive a survey link. It's very brief. We would greatly appreciate if you would fill it out. It helps us, informs us on how we should think about future webinars. So, with that, Ken, Dr. Doyle, thank you so much, and thanks to all of you who joined us today.
Ken Stern: Thank you, Maria.
Dr. Sara Doyle: Thank you.
Maria Thomas: Bye-bye.
