Please note that this transcript was auto-generated by the webinar technology platform used. We cannot guarantee its accuracy.
Maria Thomas: Welcome hello everyone we'll be getting started in just a moment as you all are settling in please take a moment to familiarize yourself with the zoom functionality at the bottom of the screen you will see uh a chat function you will also see a Q&A function as well as a show captions function and you can use all of those during the course of this webinar if you feel like chatting now feel free to weigh in and tell us where you're uh registering in from please note that if you do comment in the chat we will be able to see your name um if you want to ask a question anonymously you should use the Q&A functionality and you'll need to check the box uh that says that you want to be anonymous
Thank you thanks everyone we will start in just a moment
I also want to mention that everyone who's registered for this webinar will receive a recording of the webinar after it's finished so you can listen attentively and not feel as though you have to scribble notes throughout the entire webinar welcome to those who are just joining again we'll be starting in just a moment just to reiterate if you want to say hello in the chat and tell us where you're registering in from you can do so so but we will be able to see your name if you want to ask a question anonymously please use the Q&A functionality and check that you wish to remain anonymous
Hi Wendy thanks for joining us and we'll just give it about 30 more seconds hi glattus nice to see you thanks for joining us after the webinar is completed everyone we'll be getting uh a uh recording of the webinar via email so you need feel as though you have to scribble everything down also at the end of the webinar we will be um showcasing a number of resources that we have for more information hi Beverly thanks for joining us maybe just a few more seconds
Hello everyone and I'm showing 101 so we're going to go ahead and uh get started
Introduction to Sunday Health
Maria Thomas: So officially welcome everyone uh we uh my name is Maria Thomas and we are Sunday Health um and we welcome you to our webinar this afternoon Sunday health is a new medical practice we're focusing on delivering cognitive care specifically care for your thinking and memory functions
Currently Sunday health is accepting uh new patients we are able to see patients in DC Maryland and Virginia we accept Medicare Part B we also accept cash if you're interested after the webinar in learning more about Sunday Health's care services or maybe even in making an appointment we will have information at the end of the webinar for that but this webinar is really about demystifying and defining cognitive testing and encouraging you to make cognitive testing part of your regular Health routine
Agenda and Logistics
Maria Thomas: So our agenda includes the definition of cognitive testing what to expect during cognitive testing and reasons as I said to make cognitive testing part of your overall health routine we also hope to have plenty of time for your questions as I mentioned before you can ask a question in the Q&A section of Zoom at the bottom of your screen if you want to be anonymous you actually have to check send anonymously as we're showing on the screen screen right now you're welcome to chat with us in the chat as well if you have just commentary or other things you'd like to offer and if you want to see close captions you can click click on the captioning button also at the bottom of your screen
Team Introductions
Maria Thomas: So now onto the webinar I'm really delighted to introduce my colleagues today we're joined by three of Sunday heal's highly experienced and very knowledgeable clinicians Dr Amy Sanders is a medical doctor and a board-certified neurologist she has over 15 years of experience uh specifically in dementia neurology she's offered um care to patients living with dementia and also to their Care Partners Sarah Borel is an adult geriatric nurse practitioner with over a dozen years of clinical experience and Kelly oconnell is Sunday Health's director of clinical operations and also our nurse care Navigator Kelly is also a nurse practitioner with over a dozen years of clinical experience so as you can see we've assembled a terrific team uh to share some facts with you today and we look forward to your questions so I'm handing it over now to DR Sanders
Understanding Cognition and Cognitive Testing
What is Cognition?
Dr. Amy Sanders: Thank you Maria and welcome to everyone it makes me very happy that you have all joined us today to learn more about brain health and cognition and how we test it so as Maria said I am a neurologist and since 2008 when I entered practice the major focus of my career has been on the cognitive health of older adults
Let's get to it let's start by defining cognition and I can do that with one word cognition equals thinking so now we can all go home right
Well not quite it's not quite so simple in fact most people think that cognition is really mostly memory and many times when people come to see me they they come saying doc I have a problem with my memory but when I evaluate them I find out that something else is getting in the way of their memory function and their memory is actually working just fine so cognition is more than just memory and it includes typically when we test it at least four other major areas
The Five Domains of Cognition
And we call these areas domains of cognition so there's attention that's the ability to focus and concentrate there's language this is the ability to read and write and talk and understand what is said to you there's executive function which is a kind of weird uh jargony term but it's all of the things that we do that allow us to function in a kind of executive way so long range planning mathematics multitasking uh abstract reasoning all of these things we we lump together and call them executive function and then finally there's my weakest category visual spatial abilities so this is things like the ability to read a map or to pack a suitcase or to um look at a picture and describe what's happening in the picture to copy a complicated diagram to draw freehand a simple diagram like a cube so these are all of the areas of thinking the five domains of thinking that we evaluate when we uh do cognitive testing
How Cognition Changes Over Time
Many people don't realize they don't think about it really but they don't realize that cognition changes over time indeed many people have the unrealistic expectation that they're thinking when they're in their 60s or 70s or 80s should be exactly as it was when they were in their 30s but your knees aren't the same your lower back is not the same your skin is not the same your hair is not the same so it's not so reasonable to expect that your cognition should be the same and that's in fact because it isn't and cognitive testing helps us to measure these changes over time
Here we have a Nifty little diagram down at the bottom we have on the horizontal line time so all the way at the left is maybe when you're born and all the way at the right is maybe when you turn 100 years old on the vertical line to the left that's our cognitive abilities and as you um May notice when we're born our genetic makeup is crucial for determining our um our cognitive makeup also our our environment so how far we went in school what kind of work we did and then lifetime experience and all of this determines how our experience of cognitive aging is going to unfold
For a lucky few among us there will be optimal aging and essentially no loss of cognitive function over time this is not normal it's certainly not pathological by any stretch of the imagination but it is darn totin uncommon what happens much more commonly is seen on the other three lines most of us undergo a process of typical cognitive aging normal cognitive aging and here the main thing that happens is that things get slower we process incoming information more slowly it may take us longer to remember the name of that um hot new restaurant or the movie that we want to see or the book that we just read um or even just the word that we want in the moment that we want it that's typical of of uh Co the cognitive aging process
Important Note About Memory Loss
What is never typical of cognitive aging is Frank memory loss or Frank memory dysfunction if you leave here today with only one or two learned things I want one of those learned things to be that memory loss is never a normal part of aging we used to think that it was but we now know better so so uh when somebody has objective signs of memory impairment or impairment in another kind of thinking we call that mild cognitive impairment and then dementia is just a catchall term for when cognitive um function becomes so impaired that it impedes a person's ability to live their life in their normal way
Types of Cognitive Testing
Cognitive Testing as a Continuum
Dr. Amy Sanders: I've been using a number of terms somewhat generally I want to Define them a little bit more specifically now cognitive testing is an umbrella term you can think of it as a Continuum everywhere from everything from a a very short test that may take just a few minutes to do all the way up to um a very indepth uh type of cognitive evaluation called neuropsychological testing that averages three or four hours on under most circumstances
Cognitive screening is a small part of cognitive um uh testing the cognitive assessment really constitutes a much bigger part and you can see that depicted there in in that uh uh graphic um with the two circles
Cognitive Screening
So what is a cognitive screening it is a short test uh usually just um minutes to administer often happens although not always but often happens during a routine visit maybe done by a nurse or a medical medal assistant it is a required component of the Medicare annual Wellness visit although it doesn't always happen there
By definition a screening test is an early warning system to pick up signs of a possible underlying disease before symptoms have appeared also by definition it should never be used to make a diagnosis and uh you may have had a cognitive screening in the past often times people are asked to draw a clock for me and many people are puzzled by this
The Clock Drawing Test Example
A clock is a qualitative test the meaning that your clock is good your clock is not so good so there's no quantitative way that um groups of people's clock expertise can be compared but when we look at a clock we can often tell whether it's normal or abnormal so on the left you have a normal clock person was asked put numbers in this circle to make it look like the face of a clock and then they were asked to show the time as 10 minutes after 11:
Moving one to the right we have someone who has mild cognitive impairment and here the clock still looks pretty good all the numbers are there maybe not precisely where they should be and the hands are not quite as precisely drawn as they were on the normal clock moving again to the right here we now have somebody who has a mild or moderate dementia something like Alzheimer's disease and here the clock is not normal anymore you can tell the numbers are eccentrically placed some more than others number 10 completely missing and there are no hands there's a sketch of an idea that might have been hands but it's not hands and then all the way to the right is uh somebody who has a late stage of something like Alzheimer's disease and they are all representation of the clock face has been lost
Cognitive Assessment
So what is a cognitive assessment then well this is a much more indepth evaluation of those five domains of thinking that I mentioned attention memory language executive function and visual spatial ability takes a minimum of an hour usually requires a separate dedicated appointment and typically a referral because usually these tests are done by Specialists
A neuropsychologist is a psychologist with a clinical doctoral degree who has done beyond the doctoral training um training to learn how to examine the brain as an organ of thinking and uh a cognitive assessment is an essential though certainly not the only um component of making a cognitive diagnosis
Benefits of Cognitive Assessment
So what do you get out of an assessment the testing certainly helps me to make a diagnosis but it has benefits for you too it helps to get give you a sense sense of how your thinking is compared to people who are similar to you in age and educational background helps to identify where your thinking is strong and where it's weak and sometimes we can figure out ways to make the strong areas bolster up the weak areas
And finally it can help us to determine whether there are other aspects of your medical background that is contributing to the cognitive changes that you think you might be experiencing so this could be everything from other medical um conditions uh stress anxiety depression or even medications that have cognitive um side effects
Q&A: Important Distinctions
Dementia vs. Alzheimer's Disease
Maria Thomas: Thank you so much Amy uh Amy if I could just interject one quick question before we keep moving on um we had a great great question in the Q&A about what is the difference between dementia and Alzheimer's disease
Dr. Amy Sanders: No yes thank you Maria that is a really really important question and I'm so glad that somebody has already asked it dementia is a catch-all term it is nonspecific there are more than a hundred diseases that can cause dementia dementia just means that cognitive impairment is present and it is severe enough that it is impairing a person's ability to live their lives and take care of themselves in their normal way
Alzheimer's disease is the Big Kahuna of the diseases that can cause dementia accounting for by various estimates somewhere between 60 and 70% of all cases of dementia most of them caused by Alzheimer's disease also there's something called dementia with Louis bodies famously that's what Robin Williams had there is vascular dementia famously that's what Margaret Thatcher had and there's something called um frontal temporal dementia famously that's what Bruce Willis has those are the big four there are probably more than 90 others um other diseases that can cause the dementia um state which is a catchall term
MCI vs. Dementia
Maria Thomas: Amy that was great thank you and there is a followup already and I'm uh going to just add that in right now which is um what is the difference between MCI and dementia mild cognitive impairment and dementia
Dr. Amy Sanders: Okay mild cognitive impairment we think of as a possible pre-dementia State and that especially applies when memory dysfunction is part of the mild cognitive impairment it isn't always all mild cognitive impairment requires is that a person is is aware of a problem doc my memory is shot that's a subjective complaint and that's required there has to have been testing that demonstrates objective impairment in at least one type of thinking attention memory language executive function and visual visual spatial ability at least one of those areas must be objectively impaired
Yet a person must be and this is part of the definition for mild cognitive impairment still taking care of themselves living their lives in their usual fashion this is not to say that they might not be finding some things more difficult than they used to be but they're still able to take care of themselves if memory is involved on average about 12 to 15% of people might progress to early stage Alzheimer's disease in any given year that is not cumulative so if you've had MCI and you've had it for 12 years your chance of progressing is not 12 time 12 it's still just 12% so MCI is possibly for some people it is a pre-dementia state it can be caused by all sorts of different things though and memory is not always involved and sometimes and this is especially the case if um something obvious is identified a metabolic abnormality uh kidney failure for example or a lifestyle problem like not getting adequate restorative sleep if those things are treated the MCI can actually revert back to normal so it is a fluid state that is thought perhaps to be um something that people experience in transition from normal cognitive aging to the dementia State
When to Start Cognitive Testing
Poll: Have You Had Cognitive Testing?
Maria Thomas: Thank you so much Amy uh I we are going to invite um Sarah Borel to share a few things with the group right now there was a question that teased this up perfectly Sarah um there's a question that is uh when is sort of the appropriate age to start cognitive screenings and this particular person said that she has not yet had them as part of her Medicare annual Wellness visit so um before we we turn uh to to Sarah um before we turn to Sarah I think we were going to run a short poll right
Okay so this is the question and if you're seeing on your screen an answer to the question has your doctor ever talked to you about cognitive testing you can answer yes no not yet I've um proactively asked about testing and we'll see what folks in this group are experiencing
Okay we'll give everybody a minute and are we ready to pull up the results and I should me mention that the poll result the poll responses are Anonymous so we will just look at them anonymously in the aggregate uh I'm not actually seeing the poll responses yet oh here we go there they are so for many people in this group uh have not yet had a cognitive test a few have maybe about a quarter of you have and some have been acting asking proactively um and so I'm going to turn it over to my colleague nurse practitioner Sarah borchelt and she's going to talk a little bit about um cognitive testing and when to get it and how to think about it Sarah
Importance of Cognitive Testing
Statistics and Current Practice
Sarah Borel: Awesome thank you so much Maria and Amy for all of that wonderful information just as a quick recap cognitive testing is an umbrella term and that includes cognitive screenings which are simpler shorter assessments and cognitive assessments which are a little bit longer more comprehensive
Here's some interesting statistics around cognitive testing three and five adults actually say that if it was recommended to them they would have a cognitive evaluation unfortunately only 16% of older adults however have actually received that cognitive screening and as of now less than half of uh primary care physicians say that this type of cognitive screening is a routine part of their their protocol for their patients
Why Cognitive Testing is Important
So why is this important first things first it's it's very important to establish a baseline this means knowing where you are now in order to have data for future comparison this is important for you but also for anyone in your healthcare team doctors or nurses but also family or friends consider how mammograms and colonoscopies even annual Wellness visits are a part of routine parts of our Healthcare um this is similar collecting data as a snapshot of now in order for future comparison
Cognitive testing can also help us understand what our individual risk factors may be for cognitive changes and also to learn about what you can do to maximize your health here and now it it's important because it can open up a conversation between you and your family you and your healthcare team to help Empower you in your health um and things you can do now
As we've said cognitive testing is a more comprehensive thing and so it can identify some underlying issues that may contribute to cognitive changes but may not actually be true dementia as Amy defined and so this identify this cognitive testing can help identify areas in your life or in your medical health um that you can focus on to promote Better Health
Examples of Treatable Conditions
What are some examples examples a low B12 level or vitamin D deficiency or thyroid changes anxiety and depression poor sleep these are all things that can affect our cognition and we may not connect those dots and a cognitive testing can bring that to light um
Early Access to Care
Cognitive testing is also very important for helping us access the Right Care at the right time and so if there were a diagnosis of mild cognitive impairment or dementia as as Amy has defined this can help us get access to treatments earlier on um treatments that fortunately now there are some novel therapies available um and they're designed for the earlier stages either MCI or the earlier stages of Alzheimer's disease and so um as the saying goes earlier is better in this regard and it's not that there's nothing to do later down the line um it just gives us probably more options in that regard
Planning and Independence
And finally planning in healthcare we love to plan but I think in when it comes to cognitive Health incorporating um planning as early on as as better it's I don't think too far-fetched to say that our independence and our safety are two of our more treasured Assets in this life and if we know earlier on that there may be some cognitive concerns or just areas we need to focus on this can help us make plans whether it be regarding finances or advanced directives and living wills or plans regarding what you want to change in your health um it can also be things for safety such as safety in the home or driving safety and so it it allows things to come into the light that may not have been in the light for for you to maximize both your health and your safety and Independence over time
Age Recommendations for Cognitive Testing
Dr. Sanders' Recommendation
Maria Thomas: Thank you so much Sarah we have a couple more questions uh here in the Q&A again if anyone wants to ask a question feel free to submit it in the Q&A area at the bottom of Zoom if you would wish to be anonymous you must select uh submit anonymously um I do want to just recap a couple of really important things that Sarah said and maybe Amy come back to you with a piece of a question um just to to remind everyone Sarah said that uh you can get and actually Medicare does require cognitive testing as part of the annual Wellness visit unfortunately many pcps do not do it why they don't do it you know is up up for for discussion could be they don't have time could be they don't feel trained whatever the reason many people are not getting cognitive testing when they should be Amy the question coming back to you is uh specifically a question of what is the appropriate age to start to get a baseline cognitive test
Dr. Amy Sanders: I'm sorry I was on on mute still so I was answering the question and there I was on mute uh anyway I love this question If I Were King of the world not likely to happen but if I were everybody would have cognitive testing when they were 35 years old why do I pick 35 years old well it takes almost until our mid 20s for our brain physically to become fully mature this is why teenagers don't function like people who were in their mid mid 20s or older their brains are still not yet mature and then I would add you know 5 to 10 years worth of uh time to gather some lifetime experience and then I would test people at around age 35 because that's really the peak of their lifetime intellectual or cognitive abilities everything is downhill from there although it's downhill in in a very slow and gradual way
So absolutely I think that everybody should have a baseline evaluation when they are about 35 years old the real question though is is at what age should older adults start having cognitive testing well one reason that the Medicare Wellness visit is supposed to include cognitive testing is because there's a lot of medical research that demonstrates how important cognition is to aging well to taking care of oneself to managing one's other medical problems so uh absolutely positively not later than about age 65 if your um practice where you go for your Medicare annual Wellness visit test is not doing that test you might ask them if they could do it and if they can't or won't maybe ask them where you could get such testing because you believe that it's very important if people start asking and demanding this kind of testing I think that it will happen more frequently
It does take some time and one thing that is is is well recognized now is that Primary Care practices or pcps are um very very much under the gun in terms of time they have many patients and they they're not permitted much time to see each of them which can make getting this kind of testing um a bit challenging there are some ways to do it online um sort of as a self test those are not very reliable though I hope that answers the question fully enough
New Alzheimer's Medications
FDA-Approved Treatments
Maria Thomas: Thank you so much Amy I'm going to keep you on the spot for a moment before I bump over to Kelly in a minute um I do I do want to say uh just for myself I think it's interesting that we as a society have come to accept and embrace the idea that on a regular basis uh women get mammograms or we all after a certain age regularly get colonoscopies and so I think what uh part of what Sunday health is trying to encourage here is that just as you do for other parts of your body or other organs have regular testing and B comparisons to a baseline so we would wish to encourage that for your brain and hence the emphasis on getting the brain Baseline
Um but Amy while you're still here there was a question specifically about uh the drugs and Sarah referred to the fact that no longer do neurologists like yourself have nothing to offer that there has been significant change in the dementia landscape in recent years including the introduction of two new drugs uh targeted specifically for people at the earliest stages MCI or early dementia could you mention uh the names of those drugs Amy and also the specific question being asked is do you need an in an affirmative diagnosis of Alzheimer's to be considered for those drugs
Dr. Amy Sanders: So yes uh the short answer is yes you do need that kind of affirmative diagnosis and there is a very important reason why as Maria and Sarah mentioned there are two new medications on the market FDA approved one was um FDA approved in I think June of 2023 one was approved quite literally last month the first one uh the one from last year the generic name is lanam the brand name is LEMBI l e q I think U MBI I it's a Japanese Japanese word for some uh something meaning um beautiful elegant something like that it's a Japanese pharmaceutical company that took this drug to the FDA hence it has a Japanese name uh The Other Drug more recently um approved is uh generically known as danab its brand name is kissla and I have no idea what that word means I don't know if it has any any particular meaning at all
Both of these drugs work by a mechanism called um their monoclonal antibodies so they circulate they're given every two to four weeks by an intravenous infusion so you can't just take a pill you have to go to an infusion center and have your infusion lots of medications are are are given this way now turn on your TV tonight and look at the ads and you will see I'm sure many medical ads about drugs that are given by infusion uh and in order to to get this drug um you must have a diagnosis of mild cognitive impairment felt to be due to underlying Alzheimer's disease or the early stages of Alzheimer's disease
How the Medications Work
The drug is given to you via an inter venous infusion it circulates through your bloodstream it crosses into your brain and then goes on a targeted mission to find amalo protein abnormal Alzheimer's amalo protein abnormal amalo protein is one of the two main proteins that cause Alzheimer's disease we're pretty sure that that's true we're not entirely sure I haven't worked out completely yet how abber amalo protein causes Alzheimer's disease but we know that it does and these drugs can clear that abnormal ameloid protein out of the brain so they're fairly powerful drugs at least in a physiological way
Somewhat less is known yet about just what impact they have on cognition but in general terms for lanam the first one that was approved lmbi um it was thought that taking lmbi for somebody with mild Alzheimer's disease could be the equivalent of at least five months worth of additional reasonable cognitive functioning and boy if you're planning a family wedding or a major trip or something like that having those extra five months could really really be a big deal
Side Effects and Requirements
Uh what are the side effects I mentioned that that it's important to know for sure that somebody has the condition that these drugs are are designed to treat before giving them because they do have some fairly significant side effects known as ameloid related Imaging abnormalities or ARA for short they can cause brain bleeding they can cause brain swelling most of the time that's manageable but these are pretty significant side effects so we want to be sure that we're that this drug is not being given to people who do not have the underlying condition that the drug is designed to treat
So yes you do have to have an affirmative diagnosis and there are very specific requirements about how that affirmative diagnosis is determined it is not sufficient to have cognitive testing or to have a physician say this patient has Alzheimer's disease
Sunday Health Process
How the Evaluation Works
Maria Thomas: Thank you so much Amy for that thorough answer there are some more questions I want to acknowledge that we're reading them all and we're getting to them I'm going to ask my colleague Kelly Kelly oconnell who's our director of clinical operations and also a nurse practitioner to tell you a little bit about how the process actually works at Sunday health and that will answer a couple of the questions that I'm seeing in the Q&A so turning it over to you Kelly
Kelly O'Connell: Right thank you Maria this is an excellent question and so here at Sunday health things start with a phone call with me um our our nurse care Navigator during which I ask you to share what if any concerns you are having right now as well as describe any medical history or family history that you'd like to share and then we review what our services are to make sure that they're in alignment with your needs and goals and if so review our process
So after this phone call um if you're deciding to move ahead and schedule I would send you a an email with um details of preparing for your first appointment which includes a computer-based interactive assessment which folks have reported can be quite fun it also includes two screeners of mood because we know that there is a um strong inter relationship there between our mood and our cognition and vice versa
After you've completed that you will have your um first Sunday Health visit which is with one of our nurse practitioners um you're having the opportunity to meet Sarah now and our other nurse practitioner is Mallerie quinette during this first visit which we call a brain health assessment you um will have a comprehensive review of your medical history and your medications an in-depth discussion about what we call a cognitive history during which you'll have questions about um your education and occupation and then there'll be additional testing completed um regarding your uh cognition and um mood potentially about sleep as well
And after that point you'll receive those results and those results will determine what the next steps are in the process so those things might include labs and imaging and then ultimately moving on to what we call a brain health plan visit for individuals who um do not have any symptoms of cognitive decline and then for those people that do have symptoms of cognitive decline identified during their initial appointment they would go on to have an appointment with Dr Sanders for neuropsychological testing
Involving Family Members
Now before the neuropsychological testing we asked the patient to ID identify a family member or friend who can contribute to their Care by providing information about how um they are in their everyday life and what if any role cognitive changes may be having and that information is um hugely important in understanding again how the person's cognitive changes are impacting their their day-to-day life and DR Sanders will incorporate those answers in her overall report and interpretation of the neuropsychological testing itself
That testing takes about an hour long and then during a next and final visit you which you'll have with Dr Sanders you'll receive the results of the neuropsychological testing as well as any recommendations these recommendations could include um labs and imaging as well as um medications or changes to medications that you're currently on as well as recommendations for things regarding sleep um and and more
Diagnostic Requirements for Alzheimer's
What's Needed for Affirmative Diagnosis
Maria Thomas: Thank you so much Kelly um I want to remind everyone listening that uh at Sunday Health we are licensed to practice in DC Maryland and Virginia we are taking uh new appointments if you're interested in that um here's some information which we'll show again this is all on our website we do have some unanswered questions though so we're come back to that um and by the way Sunday health does not require a referral I don't think anyone asked that but I'm going to share that um Amy I'm going to Direct One in your uh to you which is um somebody has asked uh what is required for an affirmative diagnosis of Alzheimer's disease
Dr. Amy Sanders: All right coming off of mute and here's my there I am okay so uh yes um thank you for asking that um I queued it up for you and you did exactly what I hoped you would do which was pos the follow-up question so uh these days um generally speaking it is necessary that one have evidence of deposition of excess ameloid protein in the brain you can't get that through cognitive testing you cannot get get that via an MRI or a CAT scan because MRIs and CAT scans cannot see abnormal amalo protein in the brain
In order to see amalo prot abnormal amalo protein in the brain you need a pet scan so a pet scan is kind of like a um glorified CAT scan um that involves the injection of a um radiographic Tracer into a vein in your arm then you go have coffee um while the Tracer circulates through your body into the brain where it binds to this is what the Tracer is designed to do it binds to abnormal amalo protein so just like the monoclonal antibodies bind to amalo protein so too does the pet Tracer pet Tracer doesn't have any therapeutic benefit but it certainly has diagnostic benefit it allows us to make a diagnosis sort of um mostly uh so the Pet Scan can allow us to see abnormal um amalo protein in the brain
And you must either have a positive amalo pet scan or other evidence of excess amalo in the body the way that as of this moment um is FDA approved that non-pet scan wise um to get that evidence is through a lumbar puncture more familiarly known as a spinal tap most of the time these days that's done in an Interventional Radiology Suite under um fluoroscopic guidance um so that um person only has to be punctured once um it can be done bedside um but there it's a little bit more of a so-called blind stick uh and then the the cerebral spinal fluid levels of amalo protein and a few other things as well are are evaluated and you have to have certain levels in order to um meet criteria for um getting one of these medications
Future Blood Tests
In the near future most people say this is going to be in years I maybe even measured in months we will have blood tests that will be able to do um this confirmation of ab abnormal um Alzheimer's disease pathology in in the body there are several blood tests um already available um they're not yet FDA approved to be able to um suffice for making the diagnosis of Alzheimer's disease in order to to give somebody one of these medications but we're going to get there soon
Insurance and Practical Information
Coverage and Service Details
Maria Thomas: Thank you Amy um a couple of questions have come up that I'm going to take uh involving insurance and other questions like that first I wanted to remind everybody that Sunday Health's care services are today offered virtually so that means that your interaction with Dr Sanders or with Kelly or Sarah would be just like this via Zoom that makes it very convenient for you um and also makes it quite private uh and we also have very little wait time as a new practice so if you're looking to uh get evaluated soon we can accommodate that provided that you live in Maryland DC or Virginia and that you're covered by Medicare Part B
Someone had asked if most insurances cover the more thorough cognitive assessments I don't think we can speak on behalf of most insurances we can tell you that um Medicare does cover this type of uh testing and assessments uh and if you have a metag gap plan or supplemental plan then obviously that would cover the 20% that would otherwise be due from the patient but if you have a commercial plan at this point you would need to check with your commercial plan provider we do offer self-pay options you can read about those on our website we have both a uh kind of basic brain health um test option and then the more comprehensive option as well and another question was does Sunday Health compensate doctors who refer patients and the answer is no we do not compensate doctors who refer patients to us
Additional Q&A
Repetitive Behavior and Memory Concerns
Maria Thomas: Um there was a question a while back we didn't get to Amy I'm going to come to you and then another one that I'm uh hoping that uh any of the clinicians can take including Sarah and Kelly um but Amy the question earlier was uh somebody was speaking about I believe a relative who um has maybe some short-term memory problems whereby they repeat the same story um uh over and over and the question was is that normal cognitive aging or reason for concern I'm paraphrasing forgive me I'm not reading the question directly
Dr. Amy Sanders: Sure that's a great question um and it speaks to repetitiveness so everybody repeats themselves every now and again I've probably repeated myself several times already in this uh webinar so some degree of repetitiveness is normal happens in the normal course of events a pattern of unusual repetitiveness I think should be caused for concern it is nowhere near a diagnosis and it may be due to something that is not a cognitive um problem could be due to bad sleep or or or stress anxiety something like that however in many cases it is an early warning sign kind of a a canary in the coal mine if you will terrible metaphor I apologize for that uh but repeating oneself telling the same person the same story over and over again in an unusually short period of time or asking the same person the same question repeatedly in an unusually short period of time that may be an early warning sign of short-term memory dysfunction and I would I would I would argue that in in every case of that kind of repetitiveness it is absolutely worth being seen um and please tell all your friends that that's the case
Non-Pharmaceutical Interventions
Maria Thomas: Thank you Amy I'm sorry there's a short delay and I'm coming back on to uh the video I did want to acknowledge that um we saw the question a very specific situation involving a couple of different drugs um I want to suggest uh to whomever asked that question that maybe you e email us at hello suunday health.com and we could take that one offline because it is is quite uh specific there was another question about um that I'm going to open up to any of the clinicians uh and uh Kelly or Sarah if you want to kick it off or Amy whoever wants to kick it off it was about uh again I'm paraphrasing suggestions for non Pharma or non-drug interventions
Sarah Borel: I can I can start and Amy please chime in um so so I love this topic because I think our health is um multifactorial we' like to think about things a little more holistically and so one of the approaches we've we've taken to addressing cognitive changes that we're seeing is is looking more extensively at what is going on um including your medical health but in other areas of life as well so how are you sleeping how are you resting how are you eating uh what are you eating what's exercise like what's movement like in your life or what are any barriers to that um how's your mood what are things um that affect your mood has it been changing um and and what are your social connections like there's a lot of good evidence to show that each of these areas have pretty significant impacts on our cognitive Health individually and collectively and so we like to to hone in on things that may be areas of concern within those areas um so helping people identify ify okay what are my barriers to exercise how could I improve that within reason for my life and and what's going on for me or uh what's going on with my sleep and how can I impact that and so um while I don't have a bulleted specific list that you could maybe take home with you right now I think those are some areas I would really encourage you to look at for your own life to think about as affecting cognitive health and they are things we specifically uh try to focus on for each individual I hope that helpful
Dr. Amy Sanders: Thank you um also just to talk briefly about uh non pharmacological approaches to caring for somebody even after a diagnosis of some sort of dementia um has been made used to break my heart when people would say well there's no point in my going to the doctor because the doctor can't do anything well for a long time our treatments our medical pharmacological treatments were not so great it's true but boy there are ways that we could help people so helping people Care Partners and patients themselves figure out sort of what is most important where are the problems and how to respond when there is a problem so imagine that Grandpa gets agitated as the the day winds down a very familiar phenomenon uh to people living with dementia it's called Sund Downing and you know um there are ways to ameliorate Sund Downing to make it a little bit less intrusive into life to make it a little bit less of a problem um and you know we could do a whole webinar just on that topic alone so that's just one example from many that we could discuss um of of ways that we can help even after somebody has received a diagnosis of a disease that causes dementia it's it's it's why I get out of bed in the morning
Concerns About Facility Placement
Maria Thomas: And we're so glad you do Amy um the questions are continued to roll in so I'm going to continue we had an interesting question that was submitted ahead of time uh that Amy I am going to bring back to you and the question is if an elderly relative is given a psychological evaluation or other cognitive test can the doctor have her put into a facility
Dr. Amy Sanders: The short answer to this question is oh my goodness no at least not in the kind of of cognitive assessments that we do obviously if somebody is suicidal that's probably the main thing that that that would get somebody admitted to a psychiatric facility but again one reason that I get out of bed in the morning is is to help my older adult patients with cognitive impairment live their best lives and that does not mean consigning them to an institution we want to do everything that we can working with our patients and their Care Partners to maximize their safety at home there ways to do that so that they can live their best possible lives for as long as possible um and uh and and and Thrive without being cons igned to an institution that is always an option of Last Resort sometimes it does become necessary but there are many many things that we can do um before we get to that point and we want to push that point off into the kickback can down the road as far as we possibly can um so the short answer is is is is no um we're not going to um consign anybody to um an instit ution one moment um earlier than necessary also we do not have that power that would ultimately then be determined by the the the the rest of the family and circle of loved ones
Genetics and Dementia Risk
Maria Thomas: We're going to continue with the questions I do see a couple people having to drop off and so I just want to take this opportunity to remind everybody um that you will be getting a recording of This webinar there's also additional resources on our website under Sunday insights at the top of the page we have a number of blog posts many of which were authored by DR Sanders that speak to some of the questions that have been asked here the next question uh Amy is can you speak to the genetic piece of dementia my understanding is that later onset of dementia is less likely to be genetic speaking from a history of grandmother and mother with later onset dementia so this person is asking about the genetic element uh of dementia
Dr. Amy Sanders: So yes there is one in fact there are two so for some dementing diseases Alzheimer's disease and frontal temporal dementia especially there are genetic mutations that carry Destiny in other words if you have one of these genetic mutations and you would have it when you were born your destiny is that you're going to get Alzheimer's disease or or or frontal diens frontal temporal Dimension um those are very very uncommon and they tend to cause people to get sick younger than usual they are the main um one of the main things that can cause um early onset Alzheimer's disease which is by definition Alzheimer's disease that kicks in when a person is younger than age 65
There is something that is called called a vulnerability not Destiny but vulnerability polymorphism so it's not a genetic mutation it's an area of the The genome in a particular Gene called APO lipoprotein e or apoe for short there's a particular little spot on that Gene called the Epsilon alil alil just means spot in the gene where you can have one of three different varieties of genetic material and one of them is is neutral doesn't affect risk one of them is probably protective not 100% sure but pretty certain and the other one is for all intent and purposes known and everybody believes is is is um something that causes increased risk of developing Alzheimer's disease so not Destiny you can have you get one one of these alals from each parent so you can have two bad alals alal associated with risk and live into your mid90s and have normal cognitive function how do we know that because those people have been identified and studied they've probably got some other factor that is protecting them from the bad impact of um having uh you know two versions of this vulnerability enhancing Pol polymorphism we don't yet know what that protective factor is so apoe testing that's vulnerability and increased risk roughly 25% increased risk of developing Alzheimer's disease if you have a first deegree relative that's a parent or sibling um who who had the disease that's very helpful we're gonna try complicated topic yes indeed
New Blood Tests
Maria Thomas: Um we're gonna try to sque in two more questions quickly uh since you were just talking about testing Amy could you touch touch very briefly on um the new blood test someone is asking about um Effectiveness maybe you could just say on what they are and then just a few quick words about them
Dr. Amy Sanders: Sure there there actually is a bevy of of of new blood tests um for Alzheimer's disease ones that you may have heard of would be an amalo ratio so that can compares the level in your blood or cerebral spinal fluid of normal amalo to the pathological Alzheimer's disease causing amalo and if you have if your ratio is elevated Beyond a certain level then it's thought that you have more of the bad kind of amalo that you then you should have um the blood tests that have been making the news recently both actually test to um Tau that is a um the second protein that goes wrong um in Alzheimer's disease kind of goes Rogue and there are two blood tests for to now um one of them called Pau 217 is thought to be the more effective of the two and in a number of studies that are now you know being published in the medical literature um ptow 2117 has comparable um diagnostic ability to um the levels of am of sorry of toao in the CSF the cerebral spinal fluid cerebral spinal fluid testing already has FDA approval the TOA tests do not yet have FDA approval my understanding is that under certain circumstances Medicare may now be covering those tests I do not yet have independent verification of that fact but um things are changing and even if Medicare or or a commercial payer does not cover the blood tests they are in any case going to be dramatically less expensive than having um a spinal tap or having a pet scan
Closing and Resources
Maria Thomas: Thank you um I'm afraid we don't have time for more questions I do want to point uh participants to our website Sunday health.com at the top of the website you'll see a link to insights there is a uh there are a number of articles there some authored by DR Sanders that include um answers to some of the questions that have been asked that we didn't get a chance to touch on the relationship between mood and dementia for example also a quick article about the blood test that DR Sanders was just uh talking about so thank you all for participating again we are Sunday Health at Sunday health.com um we have a number of resources available to you you've seen
uh a portion of our care team and and clinical Talent here today if you are interested in following up with us please reach out to us either by phone at this number that you see here on the screen or via email hello Sunday health.com we are accepting new patients no referral required um and we do take Medicare and we do take cash and again we thank you all for attending um and we wish you well uh with the rest of your week
I oh just remind seeing reminder here forgive me for jumping back in we do have a presence on all of the social media channel so if you'd like to follow along and continue to get information from Sunday Health you can see uh you can find us on Facebook and on YouTube and again as I mentioned our insights area of our website which is our blog so thank you again all for attending and we'll look forward to hearing more from you
