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Doug Elwood, MD: Hello! There! Welcome everyone!
I am Dr. Doug Elwood. We're going to get started here in just a couple minutes. If you're looking for the new era in cognitive care you got—you're in the right place.
We'll give everyone just a couple more minutes and then go ahead and get started.
While we're waiting, excuse me, while we're waiting, I just want to talk about a couple logistics. There is an element here where you can put in questions. We will be doing a Q&A at the end of the session. But please feel free to put in questions as we go, and we can try to get to them if we can as we're going through the various discussion topics.
Again, welcome to those who are just joining. We have a good audience here today, and we'll be discussing the new era in cognitive care, and we'll just get started in probably just 1 minute.
Alright, I think we're nearing a number of participants here that we can go ahead and get started. Thank you again for everybody joining. We're really excited to have you here today. We're going to be talking about the new era in cognitive care, shifting from subjective to objective. I am Dr. Doug Elwood. I am the chief medical officer of Sunday Health.
Quick background about me: I did my training at Jefferson Medical College in Philadelphia before going to NYU for my residency. I am not a neurologist, but I am a PM&R physician or rehab physiatrist—goes by a lot of different names. So I have a lot of experience in brain health, but I'm not a neurologist. I've spent a large bulk of my career also focused on enhancing access for specific subpopulations. So I have been very honored to be part of some great programs and early identification and opening up access for individuals who otherwise wouldn't have it through different programs. I've been focused on dementia now for a few years, and mostly got into it for family personal reasons, and when I saw there was a pretty big gap in the space, so wanted to get more involved.
And again, just to remind everybody from a logistics perspective, there is a Q&A at the end, but feel free to post questions. I'm very happy to be joined today by 2 experts in the field: Dr. Amy Sanders, who's a cognitive neurologist from Sunday Health, and Dr. Aaron Greenstein, who's the clinical advisor for BrainCheck.
I'm going to let them introduce themselves. But quickly, I just want to tell you about Sunday Health. We are a specialty practice focused on cognitive care. Thank you for the slide, and we are live in DC, Maryland and Virginia, and opening up in new geographies around the country as well. We are very passionate about the idea of early identification, and as you will hear a lot about today, there's a great shift happening in this field that we feel like we need to make sure that we can capitalize on for patients' benefit to make sure that we are moving the conversation to early identification and try to prevent and delay the worsening of the cognitive decline.
We do have an in-office location in Vienna, Virginia, and we do telehealth as well. So with that I will hand it off to Dr. Amy Sanders for a quick introduction, and then we'll go to Dr. Aaron Greenstein for his as well.
Dr. Sanders?
Dr. Amy Sanders Introduction
Amy Sanders: Thank you, Doug. Yes, so my name is Amy Sanders, and as advertised, I am a cognitive neurologist. So I went to medical school in Brooklyn at Downstate Medical University, and as I was getting to the end of medical school, I was pretty darn sure that I was going to be some kind of doctor from the neck up.
And I was not going to do ENT—neck anatomy was way, way too scary. So I was either going to be a neurologist or a psychiatrist. At that time in my life I was all into tangible things and neurology. If you remember the horrors of neurology when you were a medical student, is all about pathways and localization and that sort of thing. Over the course of my career I have become sort of the most psychiatrically oriented neurologist I, at least have ever met. And probably, if I had had more courage when I was finishing medical school, I, too, would have been a psychiatrist. But I'm a neurologist, and the sole focus of my career since I entered practice in 2008 has been able to provide the best possible care for older adults with cognitive decline and dementia, and I have done that in various places.
I started my career, hoping to be a researcher. So my first job was working at the Einstein Aging Study in the Bronx, a very long cohort study. I then spent some time in Central New York, which was not so interesting from the dementia perspective, and then I spent 5 years in Connecticut at Hartford Healthcare, where I was the founding medical director of a multidisciplinary ambulatory memory care center. And I have been working with Sunday Health since December of 2023, and we are primarily—at least a telemedicine practice. So I live in Connecticut, but I can see patients in DC, Maryland, and Virginia, and, in my opinion, one of the great unexpected consequences, or really booms, if I may say so, of the COVID pandemic was what it did to bring telemedicine into prime time into the limelight. So that's sort of me in a nutshell, and I'll hand it off to Dr. Greenstein.
Dr. Aaron Greenstein Introduction
Aaron Greenstein, MD: Hard act to follow there. Thank you. I'm Dr. Aaron Greenstein. I'm a geriatric psychiatrist—fellowship trained and board certified. We're a pretty rare breed these days. I think about 40 people nationally do this specialty training every year, even though the fastest growing demographic in our country is 65 and up.
I had gotten to geriatric psychiatry from a combination of incredible mentorship, but I also grew up around my grandparents, who were Holocaust survivors and carried a lot of trauma with them that really was never addressed by the healthcare system. And my grandfather also had Alzheimer's disease throughout my childhood, so a lot of personal reasons that I ended up going into the specialty. I went to New York Medical College, and I did all my training, residency, and fellowship in the Harvard system. I also have dipped my toes in a lot of other things. I did the health and aging policy fellowship. I currently am the public policy chair for the American Association for Geriatric Psychiatry. I see geriatric psychiatry patients with most of my time, and I also do clinical advisory work for BrainCheck, where I work with our teams, and I also work with customers. My passion area is helping folks better understand cognitive testing and what to do with cognitive testing results, especially at the primary care level. And I spend time doing research actually on this specific topic of how to manage dementia better at the primary care level and how to interpret cognitive testing.
Just for some background on BrainCheck: BrainCheck is a digital platform, not just a cognitive assessment—a digital platform that helps clinicians streamline overall cognitive care. This is from initial screening to assessment, care planning and monitoring tools like the BrainCheck Screen and the FDA cleared Assess battery, make it easy to quickly detect signs of cognitive impairment even remotely and build personalized care plans with centralized HIPAA compliant documentation. What makes digital cognitive assessment tools like the BrainCheck unique is that it's really easy to work it into your clinical workflow. It is far more detailed than traditional paper and pencil cognitive screening batteries, and it is also reimbursable from Medicare and insurance.
And I would also just add on that it can really help with the bottleneck of referrals to neuropsychology, where there are tremendous backlogs, especially for neuropsychologists taking Medicare.
Evolution of Screening Methodologies
Doug Elwood, MD: Excellent. Thank you, Dr. Sanders, Dr. Greenstein, for the introductions. As you can tell, we have some real experts here today, and I see that some new participants have joined. Thank you. You're in the right place if you're looking for a new era in cognitive care, and we're very excited to be talking with Dr. Amy Sanders and Dr. Aaron Greenstein. Dr. Greenstein, I think we'll come back to you to start, if you don't mind just walking us a little bit through the evolution of screening methodologies, and where we are now. You just mentioned a bit of it, but if you can expand on that—how they compare against the paper based where we were, where we used to be, and then maybe give some case examples. If you don't mind walking through that.
Aaron Greenstein, MD: Sure. So I will say that there are screening tools that are frequently used in the primary care setting. Some of the really popular ones are screeners like the Mini-Cog, MoCA, MMSE, SLUMS. These are the ones that a lot of us are trained on in medical school and residency.
And they are validated, pretty good tools. The screeners have been integrated into the Medicare annual wellness visit. It's a mandated task, if you will, in order to bill for a Medicare annual wellness visit and the goal of CMS adding that into the visit is to try to push us all to do a better job of capturing cognitive decline and capturing it early.
The idea—I don't know when the idea of digital cognitive assessments actually came to be. But I'll just talk about the BrainCheck. It's the one that I know best. So the BrainCheck—the BrainCheck Assess, I should say—is a digitized version of common neuropsychological tests. For example, Trails A, Trails B, Stroop, Digit Symbol Substitution. And because it's a digitized version of those tests, these are tests that are tried and true and familiar, and at least specialists like me really know what to do with those results. I think for primary care, there is a level of education and training that's needed. One thing that I think is great about BrainCheck is that it is a far more detailed cognitive test than any of the paper and pencil tests that are commonly done, and this can give you a really great leg up in terms of making diagnosis in clinic at the primary care level or neurology level or psychiatry level and not waiting for a long period of time for neuropsychologists and others to get involved in order to confirm a diagnosis, and really can speed things up, and that in itself is really beneficial, especially at this point in time where there are patients who are candidates for therapeutics that can actually slow disease progression.
Doug Elwood, MD: That's great. Thank you for walking us through that. Are there any case examples that that might be helpful as we think through this? You know, how to use when to use the benefit of it, etc.
Aaron Greenstein, MD: That's great. Yeah. So it really does vary from practice setting to practice setting and workflow. But some examples, I'd say, at the primary care level: one thing that you can think about doing is using our screener, which is separate than our assess during Medicare annual wellness visits. And if you do find that a patient has deficits on the screener, you can have medical rationale to give them the more detailed assessed battery which will give you a really good idea of what to do next. That's a really common case. I would also say that BrainCheck is really great at capturing when people do have common patterns of cognitive decline. For example, amnestic memory loss, which is pathognomonic for Alzheimer's disease, or alternatively deficits on domains of cognition that are more consistent with conditions like vascular dementia or Lewy body disease. So BrainCheck can capture a lot of that and can allow you to pretty quickly streamline patients to neurology for evaluation, thus bypassing the long historic wait times of additional cognitive testing before additional workup happens.
Doug Elwood, MD: That's great, and maybe just one other question, if you don't mind, Dr. Greenstein. One thing that we've appreciated in partnering with you is the usability of it. Maybe you can speak to that a bit.
Aaron Greenstein, MD: Yeah, I mean, the goal is to make cognitive testing really accessible and usable. BrainCheck is self-guided. So you don't actually have to sit in clinic and walk the patient through the cognitive assessment or screener and that's a huge time saver, and it's designed in such a way that you can really implement it into your workflow, regardless of what the workflow looks like. We have cases of all kinds of workflows and it can easily be integrated so that it doesn't end up being a burden clinically, and that it's actually a major value add without creating a lot of friction.
Blood-Based Biomarkers
Doug Elwood, MD: Excellent. So we're going to shift just a little bit. But we're going to go to Dr. Sanders and Dr. Sanders, big news on Friday about the biomarkers, so I'll lead off with that—not to steal your thunder at all. But we'd love to go into the biomarkers if you don't mind. Tell us about the new blood-based biomarkers, what happened on Friday, and we'll get into it from there.
Amy Sanders: Thank you, Doug. This is a pet sort of project of mine, so I'm always happy to talk about blood-based biomarkers for Alzheimer's disease. And I'm not talking about vitamin B12, or thyroid function tests, or anything like that. So historically and certainly when I was in training, I was taught that if you have somebody who has cognitive weakness or cognitive impairment when you see them, it is incumbent upon you to rule out reversible causes of dementia. Well, we don't really believe in reversible causes of dementia anymore. But it is certainly true that metabolic problems like B12, thyroid dysfunction, that sort of thing can exacerbate any pre-existing cognitive dysfunction. But, boy, do we have better stuff now?
So over 2 years ago now, I think maybe even as much as 2 and a half years ago, Quest, which is everywhere in Connecticut, started offering the amyloid ratio test. And I'm not typically such an early adopter, but I was a pretty early adopter for this one, because it was actual information. At that time I had no access to amyloid PET because it wasn't yet approved in clinical medicine. It was only allowable in research settings, so I couldn't gauge somebody's possible amyloid status by getting them an amyloid PET. I don't like to send patients for LPs under fluoro and most patients I've encountered don't appreciate even the suggestion.
And now, since the amyloid ratio test came out 2-3 years ago, we have more. So the amyloid ratio test capitalizes on the fact that when abnormal beta amyloid gets deposited into neuritic plaques—extracellular neuritic plaques in the brain—virtually by definition, the amount of available beta amyloid Alzheimer's beta amyloid, available for circulation in the peripheral circulation goes down.
So we can look at the ratio of bad Alzheimer's protein to normal amyloid protein. And that gives us information. So for LabCorp, for example, if the ratio drops below 0.102, then that is considered to be a positive screen. These tests are frequently referred to as diagnostic tests, and they certainly help with diagnosis, but by themselves, they cannot make the diagnosis.
The diagnosis has to be part of a comprehensive assessment that includes things like biomarkers and blood tests, but doesn't rely solely on them. So we have had the amyloid ratio for several years, and I'm not going to bore you with—I don't even know off the top of my head when all of the other ones first came into being. But we frequently and routinely check 2 tau isoforms.
Hyperphosphorylated tau protein is the central ingredient, if you will, in the famous intracellular neurofibrillary tangles in Alzheimer's disease, and we can check 2 tau isoforms. We can check P-tau 217 and P-tau 181.
Given the news on Friday, I think it's possible that P-tau 181 is going to get a whole lot less love going forward because P-tau 217 has become probably the most powerful Alzheimer's disease related biomarker that we have. It has AUCs that approach those of or equal, really those of CSF.
And now we can combine the amyloid ratio and P-tau 217 into a single blood test. This is what was FDA approved—I think it was even in the late afternoon on Friday, and so we now can get really a lot of information from a single blood test. So that's going to be, I think, better for patients, because the way that the amyloid ratio is always reported, they give you the values for the numerator and the denominator, and I kind of expect, although I haven't ordered this test yet, but I expect that that will continue. So you'll get to see the P-tau 217 level and the amyloid numbers, but they will be then combined and reported as a single ratio. So that means that the patient has to have one blood test, means the patient has to pay for one blood test, or at least that is my expectation. And the other thing that is very, very important about these blood-based biomarkers is that I've talked about the amyloid ratio which capitalizes on amyloid protein, and then we have the P-tau 217, which is a tau biomarker. But when you're testing in Alzheimer's disease, what both of those tell you is about the likelihood that the patient has underlying amyloid pathology.
There's not yet clear and convincing consensus that P-tau 217 will be sufficient to replace CSF or amyloid. But given the AUCs, which are in the mid-nineties—almost certainly the low nineties, and I think maybe even the mid-nineties—and the FDA approval, I think that we're rapidly approaching the point at which we can ascertain a patient's—at least a part of a patient's eligibility for disease-modifying monoclonal antibody therapy in Alzheimer's disease, and I got to tell you that gives me the shivers.
Doug Elwood, MD: Yeah, it's really, really exciting. And I know we talk about this a lot. But it feels like early cardiovascular disease, early diabetes where the emergence of the biomarkers and some treatments completely transform the field. And it feels like we're entering that and entering it quite rapidly.
Amy Sanders: I've been hearing actually at big conferences for a good year and a half now that really we need to change our thinking about Alzheimer's disease and related dementias, but especially about Alzheimer's disease, and to think of it much more like cardiovascular disease, where the origins often are separated by decades from the symptoms and that sort of thing. So long-term prevention, and then care when care is needed.
Doug Elwood, MD: That's right. For the blood-based biomarkers, Dr. Sanders, you mentioned the 2 P-taus and the ratio. There are some other ones out there.
Amy Sanders: There are. Yes, there are indeed. So there are 2 other ones that I should mention. One is the glial fibrillary acidic protein which you can just call GFAP. That's what everybody calls it, because it's too long otherwise. So you can run a GFAP at LabCorp. I don't think Quest offers it, but or at least they haven't up till now. And this gives you—it's a nonspecific indicator of inflammation in the brain. So you can also run a neurofilament light chain. And actually, if you do the so-called ATN profile at Quest that gets you an amyloid ratio, a P-tau 181 and a neurofilament light chain. One of the important things to know about neurofilament light chain, which is a marker of active neurodegeneration, seems to me that that one doesn't come back positive very much at all. I mean, I'm still in the learning phase of all of these biomarkers, and the NFL is kind of the trickiest one, because it is also implicated by comorbidities, especially renal disease, and it becomes less accurate, less helpful. Unfortunately, as the patient gets older, so it's most accurate when somebody's in their fifties.
But it is now possible to do the amyloid ratio, P-tau 217, maybe a GFAP—that would be 2 tests, and you get an enormous amount of information to sort of guide your thinking about what could be going on with this patient.
Neuroimaging
Doug Elwood, MD: It's really exciting. Turning to a different area, but nonetheless still very important in this discussion is neuroimaging. Dr. Sanders, do you mind walking us through that a little bit, and some do's and don'ts, as we think about neuroimaging, especially for the primary care perspective.
Amy Sanders: Sure. So I'm a neurologist. So I love sending people for brain MRIs. But it's important to know if you have an older adult with cognitive impairment how to order the MRI so that you get the maximal information for the condition that you're chasing.
You do not need contrast. So please don't order it with GAD. GAD does nothing, or at least doesn't help me in any way. So you use GAD if you're worried that somebody has an infection or a neoplastic process going on. But it doesn't apply in the vast majority of neurodegenerative diseases, and certainly not for Alzheimer's disease.
And then, now that we have lecanemab and donanemab, the new disease-modifying monoclonal antibody therapies that have as their major side effect amyloid-related imaging abnormalities, some of which lead to brain edema, others of which lead to brain hemorrhages which can be small and not small. And so it's very important to know, has the patient you're contemplating referring for MAB therapy ever had any sort of bleeding event in their brains. So you want to be sure that you're getting a GRE and/or an SWI. If you have a choice between the 2, pick SWI, and those are—they seem to be happening more frequently. But I still, whenever I write an MRI order, I specifically mention that I would like to have those.
The other thing that you want to do if you can—it's not available everywhere. But if you happen to be hooked up with an imaging center where you can get hippocampal volumetrics, that is also very helpful because hippocampal atrophy—typically we start calling atrophy when the hippocampi drop below around 5% of the expected value for age and hippocampal atrophy is considered a structural biomarker of Alzheimer's disease.
As with the biomarkers, it's not diagnostic. You can diagnose virtually none of the neurodegenerative diseases on any kind of imaging modality—possible exception there of CJD, but CJD is kind of beyond the scope of today.
So MRIs can be very useful. I always want one. They give us that specific information about a person's—about how healthy their hippocampi are. The hippocampi should look like nice, plump, juicy grapes. If you get shriveled up raisins, your patient is in trouble.
But then the MRI can also give you information about the burden of vascular disease, which is incredibly important. And you know, cerebral amyloid angiopathy is getting diagnosed—it feels to me, I haven't actually done the math, but it feels to me as though it's getting diagnosed much more frequently because of the fact that radiologists are paying more attention to bleeding. But you can also—you want to see: have they had a history of stroke? Do they have—had they had lacunar infarcts? Do they have extensive white matter disease, all of those things?
In sufficient number can cause a dementia on their own, and they certainly can worsen Alzheimer's disease. The single most likely underlying pathology, if we could go out into, say, Times Square and look in the heads of everybody who was 65 or older, the most common neurodegenerative pathology that we would find would be Alzheimer's disease plus vascular components to that disease.
A few words about PET: amyloid PET is now clinically available, and Medicare will cover it. It's a covered procedure, and it is still required before somebody has monoclonal antibody therapy.
Interpreting the amyloid PET really should be done by somebody who's had special training in the interpretation of amyloid PET. So you might want to check that out before you refer somebody.
There is not consensus in the field about the utility of FDG-PET. I don't find it to be very useful at all. It's a nonspecific metabolic test, and you know, it's—send your patients for a big radiation dose if you're sending them for a PET. So I don't find FDG-PET to be particularly useful. But I will remind everybody that it has been since the dawn of time—or around 2010—FDA approved for the specific situation of distinguishing between Alzheimer's disease and frontotemporal dementia. That doesn't come up very often, but when it does, actually having access to FDG-PET there, at that point it can be helpful.
And then, you know, regular cat scans for neurodegenerative disease, not really useful at all unless you're worried about vascular disease and somebody who cannot have an MRI. Then maybe you could get a little bit of information. But mostly cat scans are not helpful, and they certainly do not replace MRI.
The Shift from Subjective to Objective
Doug Elwood, MD: Thanks for walking through that Dr. Sanders. Dr. Greenstein, I want to come to you for a minute, just as we think about all of that and absorb what's happening. So you talked a lot about the digital assessments. Dr. Sanders talked about some of the blood-based biomarkers, the neuroimaging. Maybe encapsulate that for us if you can, around going back to the title of this presentation is around the shift from subjective to objective. What does that fully mean? And what's the—why should we be excited about that?
Aaron Greenstein, MD: Yeah. So I think the one of the big takeaways from what Dr. Sanders just described is that you cannot diagnose and stages of the dementia based on the biomarker studies and imaging studies alone.
At present we still have to use cognitive testing and functional assessments to actually stage and establish a diagnosis.
And what that means is, even with all of these advances, at least for the time being, we are ways away from being able to definitively and objectively diagnose folks with point of care tests or single tests. I don't know that we'll ever be able to for a lot of these conditions, maybe for some of them.
So what that means is that tools like cognitive testing continue to be relevant. And I would argue that they're even more relevant because these tests—you know, while they can be done in certain situations and given certain indications, we don't really have data at this point about how often we should be doing blood-based biomarker testing, how often we should be doing amyloid PET scans, and so on and so forth. With all these different tests. The one thing that you can do on a pretty regular basis is cognitive monitoring.
And the coverage of cognitive testing and what is the standard of care as defined by the USPSTF and other organizations to me, actually lags behind the reality, which is, we probably should be testing people earlier instead of waiting until they're people's first Medicare annual wellness visit at age 65. I would love to have a baseline on all my patients from the age of 30 or something, because ultimately, by the time a patient showed up to me, I really can't tell you what their baseline is. Neuropsychologists do their best to try to identify baseline and test based off of that. But it's really impossible without objective data. I mean, that's the reality. So to me, the big opportunity with cognitive testing is establishing cognitive baselines, early testing regularly even on healthy subjects and using highly sensitive tests to try to identify slight changes early on so that you can progress to biomarker testing and brain imaging and treatment.
And the reality is these Alzheimer's therapeutics are incredible. They're going to give people life who otherwise were going to decline quickly. But for most people with dementia, the biggest risk factor for development and progression is medical comorbidity not being adequately managed.
And it's always a good reminder that if we're going to protect our own brains and the brains of our patients, the most important things are making sure that their hypertension, hyperlipidemia, diabetes, AFib—on and on—are managed, and cognitive health also plays a role in that. If people are not cognitively healthy, it's pretty hard for them to manage all these medical comorbidities.
So everything is sort of tied together. But cognitive testing, especially really easily accessible cognitive testing that can be done at home is a great way of tracking how patients are doing, even how we're doing personally over time and getting objective testing, meaning biomarker testing, imaging testing, done much earlier than would otherwise be done.
Doug Elwood, MD: Yeah, such an important message. Thanks for saying that Dr. Greenstein. Actually, I think this question—we just got a question in the chat that I think would be for you. It's: can cognitive monitoring be more widely used in clinics, but also pharmacies. Only 9% of Medicare patients have had an MCI diagnosis.
Aaron Greenstein, MD: Yes, the answer is, it should be used more widely. I think the better question is like, what are the barriers to cognitive testing being used, and I would argue that the biggest barriers are our providers just not knowing what to do with cognitive testing results. When I was in training actually at Mass General, we did a system-wide study on primary care docs as to why primary care doctors generally don't manage dementia or want to manage dementia.
And one of the biggest commonalities between primary care docs in that health system was that people just don't know what to do next if they do have—if impairment does show up on cognitive testing. So I love the idea of testing everybody.
But if you're testing in a situation where there aren't identified next steps, you do put people in a pickle, and it's a really stressful pickle. I've seen it with my own family members. You know, people have deficits in cognitive testing and primary care docs just don't exactly know what to do or what to do next. And it causes just a tremendous amount of stress. Sometimes it's warranted stress, because there should be next steps. Other times it's not.
But there's just no system of care in place yet for cognitive testing. But as far as I'm concerned, like population level testing, which is not the USPSTF recommendation is probably going to be in the future a standard recommendation. Once there's better systems of care in place. We're just not quite there yet.
Amy Sanders: Do you mind if I—do you mind if I jump in and comment about that as well? So I often say that if I were king of the world, everybody would have cognitive testing to lay down a baseline when they were 30 or 35 years old. The brain is finally, fully, physically mature. At that point you give them a couple years for you know, gathering some life experiences that when they're 65 will be the foundation for wisdom. And then we would know sort of what that's their peak lifetime, mental cognitive performance. It's all downhill after that.
So and then I, as a neurologist, really really want everybody who's listening to know that it is never true that nothing can be done. There are always ways that we can help. These tend to be very time consuming and labor intensive, which is why clinics like us, like Sunday Health, exist. But it's also true that interpreting a cognitive testing result, especially talking about interpreting, say, a neuropsychology report—full disclosure, I'm a neurologist, and unless they use small words and really really spell out the impression at the end of an EMG report, it's Greek to me. For most of my colleagues reading a neuropsych report is equivalently Greek. It's complicated stuff.
You know, we test multiple domains of cognition—attention, memory, language, reasoning, visual spatial, usually at a minimum, and those are not hermetically sealed away from each other. They overlap—the colors run. So you really have to—you have to take a deep and comprehensive history about the patient, and then interpret their cognitive results in that setting. And that's a huge challenge, maybe even an inappropriate challenge in the primary care setting. But it's why specialty cognitive clinics exist. And we really need them now, because taking care of a patient with neurodegenerative disease requires a holistic approach. It's not just medicine. It's not just lifestyle changes. And then there are always 2 patients in the room. There's the actual patient, and then there's the care partner, and the care partner is often in greater extremis than the patient. So this is, it's complicated stuff. But, boy, we are getting some tools really to be able to attack it.
Modifiable Risk Factors
Doug Elwood, MD: And speaking of that, Dr. Sanders, a good segue to, I think our next section, which is really exploring the modifiable risk factors. Do you mind just continuing on that thread and telling us about the Lancet Commission, the modifiable risk factors and kind of the focus of that whole thrust.
Amy Sanders: Sure. So patients often fetch up—oh, this is now where you're going to tell me that I have to eat right and exercise more. Well, yes, we do tell them that. We also tell them why and try to give them, you know, some sense of sort of power over their own situation, but also to underscore the fact that there are all kinds of different directions from which we can support and affect the cognitive status of any given patient. So the Lancet Commission—big biomedical think tank based in the UK—publishes pretty regularly an update on sort of the state of dementia care, and they're quite famous for describing in great detail especially 14 different things that are the modifiable risk factors for dementia. I get up on my soapbox with every single patient I see about their auditory health.
Protecting your ears and your hearing is a great way to protect your brain. Untreated hearing loss is one of the most impactful modifiable risk factor in neurodegenerative disease. But it's only one. There are many other modifiable risk factors.
So at the big international Alzheimer's Disease Conference in 2023, we started hearing about how pernicious ultra processed food is. That completely changed the way that I counsel patients on what they should eat. I still mention the Mediterranean diet, but I then also tell them that since I heard that at that meeting I've had potato chips, not even this many times. So it really does make a difference. There are all sorts of different ways that we can intervene. One of my prayers for the next couple of years is that audiograms and hearing aids will become covered by Medicare. It's a scandal that they're not. But vision care is important.
The diet is important. Exercise is important.
Sleep—my goodness! In medical school they taught me almost nothing about sleep. Sleep is so much a part of my clinical practice now, because you know, if your patient isn't sleeping then everything can go wrong.
And I just actually had somebody who's gonna reschedule his neuropsych testing with me because he just got his miracle machine—his CPAP— and he and his spouse are already seeing changes in his cognition. So we're going to wait a couple weeks and test him once he's had his CPAP for a month or so. So sleep is incredibly important. Air pollution.
That was a new one for me when I first started hearing about it a couple of years ago, and not just the big, nasty smog that hovers over, say, Beijing or LA—microparticles stuff also that's in subway tunnels. So we're learning also about how that environment impacts risk for neurodegenerative disease. And then all of the lifestyle factors. So diet, exercise, sleep, hearing, vision.
People get their cataracts checked or fixed, but they will ignore their hearing loss until the cows come home.
So you know, any consciousness raising that primary care could do on that front for us would be greatly appreciated.
Doug Elwood, MD: And just to turn back to you, Dr. Greenstein, quickly. I don't know if you wanted to weigh in on that as well, especially from the comment you made, which was so important about just getting a baseline and underscored by Dr. Sanders as well as just—you know how we think about that, and the modifiable risk factors, and the importance of that early screening.
Aaron Greenstein, MD: Well, the one thing that I would add on just in my geriatric psychiatry lens is mental health care.
Untreated psychiatric conditions like anxiety, depression, PTSD are directly correlated with later development of dementia. They can also be prodromal syndromes of dementia. I don't want to confuse those 2, but in addition, like the sleep deprivation—if you have severe depression or anxiety in your earlier life, you are higher risk for developing dementia later on.
So it is also important to make sure you take care—take care of yourself.
And just generally, I think, to me the general rule of patients is, if you take really good care of yourself, you're doing the best you can to deal with these modifiable risk factors for dementia. A lot of it's out of our hands once you've taken really good care of yourself, and that's across all of these different domains that Dr. Sanders talked about, in addition to mental health.
Sunday Health Overview
Doug Elwood, MD: Thanks Dr. Greenstein and Dr. Sanders, just because you mentioned it. I want to go—just take this just a minute or 2 here, just to talk a little bit more about Sunday Health and the fact that we really focus on those modifiable risk factors. We are doing a lot of the assessments, including neuropsych testing that Dr. Sanders does herself.
And looking at these different categories of blood-based biomarkers, neuroimaging to paint that broad picture that, as Dr. Greenstein said, is not—they're not independent. You can't independently look at one of those and make a diagnosis. It has to be a full picture, and it can get quite complex, especially now as it's continuing to evolve and really get initiated in a lot of ways. So we do that with our team and are able to follow the patient over time. So not only hopefully—we had they come to us with a baseline, but, as both doctors mentioned, that doesn't happen very often, so we establish the baseline and then can follow them over time and be very aggressive around those modifiable risk factors as well as other things, thinking about advanced directives, home safety issues that are difficult to talk about quickly. We go into depth on. So just wanted to throw that out there as well.
Key Messages for Clinicians and Patients
Doug Elwood, MD: I'm curious for both of you. Maybe, Dr. Greenstein, we can start with you around—as we think about from a clinician lens, we have patients in front of us. Maybe they're hearing the news. It seems like there's a positive movement to a greater understanding and appreciation and the ability to talk about mental health in general, including dementia. And what's happening there? What are some key messages that you think—you already said a few of them, I think. But what do you think is important to be able to say to patients as clinicians see them.
Aaron Greenstein, MD: There's a couple of things, number one, and they're kind of tied together. So it's really important to thoroughly assess your patient.
And I'm not talking about a cognitive assessment or a physical exam. I'm talking about better understanding how they're functioning day to day and how they're functioning in their life.
And that may mean collecting data from them or from other people in their life, to really dig into how they're actually functioning, and how their cognition is impacting the overall function. With BrainCheck, we put a big focus into assessing function and we have standardized functional assessments on our platform like ADL and IADL assessments as well as dementia staging tools. All of these things—the point of all these things ultimately is standardized ways to really get to know your patient situation.
That's number one. And number 2, I will add, is that—and this is evidence based actually—is that when what is ultimately most important to patients and families when you are diagnosing a chronic degenerative condition, whether it is a dementia or other disorder is letting the patient and family know that you're going to be there for them and with them through the process.
And saying that line—as much as it sounds corny—is a massive difference maker in terms of caregiver strain, and also personal acceptance of diagnosis. And all of this ultimately reduces morbidity and mortality, because when people feel cared for and connected with their doctor provider—whoever it is—they're more likely to comply with treatment and to feel cared for, which is better for everybody all around. So that to me is ultimately the most important message. It's get to know your patient really well, and once you get to know them really well through standardized assessments which are the best way to do it, you can be really empathetic to them, and let them know that you are there for them, because you really do understand their needs.
Doug Elwood, MD: Thanks, Dr. Greenstein, really important messages. And before we turn to you, Dr. Sanders, just wanted to point out that in the chat we did drop the Lancet Commission article if you want to click there, and also just a reminder that if you want to post some questions, there's the Q&A option there as well. Dr. Sanders, same question about patients and messaging.
Amy Sanders: Yeah, I think one of the things that I always want my patients to understand is that it is never true that nothing can be done.
Going forward from today, I'm going to do a much better job about assuring my patients that I will be there for them, as Dr. Greenstein suggested. That is incredibly important, and I don't do it enough. That changes right now. So I think that many times I have heard, not necessarily from the patient, maybe never from the patient, but frequently from the care partner: "Don't use the A word."
Well, I gotta use the A word, but how you use the A word makes a really big difference. So we at Sunday Health, take advantage of Medicare's cognitive care planning codes which permit more time for seeing a patient, and that's the visit type where we usually convey the diagnosis. Sometimes patients and the care partners have a pretty good idea what's coming, and that's easier for the person who's rendering the diagnosis. When it comes as a surprise that can really be difficult. Have Kleenex ready.
And when you're talking to your patient, if it's not in a telemedicine format, sit down. Don't you know, loom over them. So there is always something that can be done, we will stay with you to do it, and there is joy to be found in every single day. I believe that with every fiber of my being. Sometimes it's a tiny little bit, and you really got to look for it. But there's something good every day, and that does not change with a diagnosis of dementia.
And the person who gets that diagnosis does not change. So I frequently tell my care partners that they have to—you know that being a natural born caregiver, I've never met one. 17 years in practice. I've never met one. That's the bad news. The good news is those skills can be taught, and places like specialized practices, like Sunday Health, but also the Alzheimer's Association and other advocacy and research organizations also are versions of help. And you know, there's joy to be found in every single day, and you know the patient remains who they've been.
It's really really important to respect that.
Q&A Session
Doug Elwood, MD: Thank you both.
I don't see any questions currently, but if anybody has any, please post them to the Q&A. We'd be happy to address them. In the meantime. Thank you, Dr. Sanders and Dr. Greenstein, and we'll see if we have any questions.
Not seeing any come up so we'll give everybody another minute to see if there. Here's a question here.
I'm interested in how digital health [affects] rural communities. Great question, Dr. Greenstein. You want to start there.
Aaron Greenstein, MD: Feel like that was a staged question. I think for all of us here, that hits close to home, and that's an issue that we're all trying to solve for. So one of the beauties of BrainCheck is that as a product that can be done from home and can be done on any device from anywhere. So it allows people who are far away from care to have access to pretty detailed cognitive testing in their home or in the clinic, regardless of where they are. And I also, you know, with the patient population that I take care of—even people who are living in urban areas with lots of medical care may have significant barriers to leaving the home and getting to their doctor's office. So whether you're living in a rural place or your home feels rural even in an urban setting, just because of all those limitations, tools like BrainCheck make care accessible in a way that it historically has not been.
Amy Sanders: Yeah. In my opinion, the advent of telemedicine and the growth of telemedicine—I really can't think of a patient population, and I admit I might be biased. But I can't think of a patient population that has benefited more from the advent of telemedicine [than] patients with neurodegenerative disease, especially once they hit sort of the moderate stage. It can be really challenging to get out of the house to a physician appointment. The patient typically doesn't want to go, and will often then decompensate for days potentially afterward.
So you know, I've seen patients in their cars. I've seen patients in their bathrobes. I typically, you know, most patients show up in their kitchens or their dining rooms, and they don't have to leave the house. They don't have to brave the weather.
You know, sometimes there are technical difficulties which you know we're all learning sort of how best to troubleshoot those. But, my goodness! What a boon it is to be able to reach people who otherwise might be a whole lot less reachable.
Doug Elwood, MD: Absolutely. And then the second part to that question is, how would you guide seniors in rural areas to be more connected.
Dr. Greenstein? Any advice on that one, Dr. Sanders, if you want to jump in.
Amy Sanders: I mean, I think the area that I live in is technically rural. But a mile from my house is a senior center, and if not a formal senior center—go, maybe explore. People can go and explore church or synagogue services. That's a good way to meet people. You know, Dr. Greenstein spoke eloquently about how important it is to pay attention to a patient's current mental health and their mental health history, isolation, and loneliness.
It's often a sort of bidirectional flow. But many times patients who are developing cognitive impairment are afraid—anxiety rises. They're sad, they get depressed. They get anhedonia. They just don't want to do anything anymore. So it can be very difficult sort of to maintain active social engagement. Human beings are social animals. We need to be with other people. So finding some place to be with other people, and you know, doing it online, probably counts, too, doesn't have to be in person. So and then how we sort of medicalize that, you know, I think it is with organizations like Sunday Health and BrainCheck, that are not so physically tied to a particular place.
Aaron Greenstein, MD: Yeah, I would second that. I think you know if somebody is aging in a rural community and they are isolated, meaning that they have limited social contact or points of contact, like online communities, are a great way to engage or services that are able to actually visit folks in their home.
One of my favorite stats that came out of that was talked about a lot during COVID was that loneliness—so, the loneliness being the sensation of not having adequate, meaningful social contact—is as distressing to the body as smoking a pack of cigarettes a day.
And again, this ties back to cognition right, having high inflammatory state due to a psychological condition, is bound to cause cognitive change, or at least physiological changes to the brain with time. So more factors that need to be modified. And if that means figuring out ways to engage folks who are in rural places and online communities, or sending people to visit them periodically, whatever that looks like. There are ways of intervening, and COVID has frankly opened a lot of those doors, right? Like, I have a lot of patients whose main point of social contact is church or religious service attendance, and because of mobility issues, or incontinence, or whatever they stop going or anxiety related to dementia and being able to attend church on Zoom or on video, has made a massive difference to folks. So I'd say the world has shrunk a lot in a lot of ways, and even though there is an epidemic of loneliness and isolation, there are a lot of ways of mitigating it. Again, this gets back to knowing your patients like, where are they able to actually engage? How can you engage them? The anxiety, the apathy, those changes from dementia can limit the ways that folks can engage. But getting to know them really well is the way to figure out how you can help them.
Doug Elwood, MD: We have a question from Dr. Lee, maybe for Dr. Sanders, P-tau 217 levels can rise with renal insufficiency. Do you know at what level of renal insufficiency that P-tau 217 elevations become confounded.
Amy Sanders: Hi, Dr. Lee! They so I have a general answer to this question, and so I'm not a nephrologist. I'm not that smart and I'm not even an internist. So I'm going to say something that may sound weird to you. But you really need a pretty good amount of renal insufficiency before the P-tau 217 values start to get confounded by that renal insufficiency, and I would say, probably stage 3—probably stage 3B of chronic kidney disease is when you need to start just wondering whether the value on the 217 that you have has been implicated by the kidney disease. I don't think I have seen yet a patient who has that degree of renal impairment—that may just mean that the patients I'm seeing are not that medically sick? At other times in my career I've certainly seen people with a lot more renal impairment. And then, exactly, you know—is there a conversion factor or anything like that? I don't think so yet, but I promise you I'm going to go look that up.
Closing
Doug Elwood, MD: Good questions. Any other questions before we close?
All right. Well, once again. Thank you everyone for joining. It's been an excellent session. Thank you, Dr. Sanders. Thank you, Dr. Greenstein, and we are recording this so we can post it if you want to pass it along to any of your colleagues [or] watch it again.
Ask us any questions. Can contact us at hello@sundayhealth.com. And the same is true for BrainCheck. If you have any other questions, want to contact them, website, phone or email.
Once again. Thank you, Dr. Sanders. Thank you, Dr. Greenstein, for an excellent session, and if anyone has any follow up questions after, please get in touch, otherwise enjoy your night. Thank you so much.
