University Place

Alzheimer’s Disease

– Dr. Rebecca Minter: Good evening. Dr. Rice and I are your Mini Deans this evening, and we’re really thrilled to welcome everyone to Mini Med School tonight. We see a lot of supporters in the audience for the medical school and the Middleton Society, and your support really makes this possible. Mini Med School really represents the Wisconsin Idea. It’s the epitome of really helping to push out all the amazing things that are happening here at the University of Wisconsin School of Medicine and Public Health out into our broader communities. So with that, I’m going to turn things over to Dr. Sanjay Asthana to get our program kicked off.

– Thank you, Dr. Minter and Dr. Rice. Hi, good evening, everyone. It’s a true pleasure to welcome and thank you all for being here. We have actually organized a very exciting evening for you. And we plan to share some cutting edge research that takes place at UW-Madison. In fact, this research is transforming care of millions of Americans who suffer from Alzheimer’s right now. As you all know, Alzheimer’s is one of the most dreaded and the costliest disease we face as a nation. The estimations are that unless we find an effective treatment for the disease, this disease alone would bankrupt Medicare by 2050 and cost the nation $1. 3 trillion every year to care for millions of Americans who will have the disease.

So the news is good in the sense that UW-Madison, about 10 years ago, to tackle this impending, burgeoning tsunami of people with this disease, established an Alzheimer’s program. And this program is comprised of two pillars. One, the Wisconsin Alzheimer’s Disease Research Center, also known as the ADRC, which is one of only 30 NIH-funded centers of excellence in Alzheimer’s disease in the country. And the distinct feature of ADRC is that this is the only geriatric-based ADRC in the country. The other pillar is the Wisconsin Alzheimer’s Institute. The WAI is supported by the NIH, by the state of Wisconsin, and the medical school, and they sponsor the renowned RAP study. Perhaps some of you are already participating in the RAP study. And in addition, the WAI organizes numerous outreach, education, and teaching programs throughout the state of Wisconsin. And they’re training the next generation of leaders and physicians in Alzheimer’s disease and research. So tonight, we plan to share some breakthrough findings in the area of what we think causes Alzheimer’s disease.

What is the difference between Alzheimer’s disease and dementia? And what are the various causes of the disease? And then we’ll take you to the area of caregiving. I’m sure that some of you are involved with the care of some people with Alzheimer’s disease. I myself was involved with Alzheimer’s disease. My own father died from the disease, and he was diagnosed with the disease at an age of 63. And as a young man, I saw him go through all the stages of the disease, and I’m fully aware of the devastations it causes. So between the ADRC and the WAI, in fact, this is the only place in the country that has a program that combines the expertise of a science-based center like ADRC, and a community-based education and training center like WAI. There’s no other place in the country that has a combination of such complementary programs. So without any further ado, I would like to launch the program and would like to invite the first presenter, Dr. Nathaniel Chin.

Dr. Chin is an assistant professor of geriatrics. He actually received his M. D. here. And then he did his geriatric fellowship and research training in Alzheimer’s right here at UW-Madison. And he’s an outstanding physician scientist, but also a great clinician. In fact, he runs a very unique clinic at the UW hospital, which cares for patients with advanced stages of Alzheimer’s disease. So I’d like to hand over and invite Dr. Chin to make his presentation, thank you. [audience applauding]

– Thank you for that introduction, Sanjay. When addressing the question of what is Alzheimer’s disease, I think it’s important that we view it from two perspectives. Now, for me, this is Alzheimer’s disease. It is the disease that changed my family. My father was diagnosed with Alzheimer’s at the age of 62. And it is the cause for his forgetting, his thinking changes, and the reason he’s in the wheelchair in that picture. It’s what led my mother to become his primary caregiver until the day he died. And it’s why I’m here today. I think there are other people in the audience here who can tell a similar story, and who are as affected by this disease as I am. But I think we have to look deeper than the people affected because when we do, we see something important. Alzheimer’s disease is actually an abnormal process that occurs in the brain because of two proteins.

These two abnormal proteins build up in the killer brain cells. Now, one protein forms outside of the brain cell, we call it amyloid or amyloid beta or beta amyloid. For now, I’m just gonna call it amyloid. The other protein builds up inside of our brain cell, and it’s called neurofibrillary tangles, or tau proteins. Now, these two proteins work together to cause problems in our brains. And that leads to the symptoms that we see in the people we care about. Now, we can see these proteins under a microscope, and that is the definitive diagnosis. But we can now find the disease in living people too. The pictures here are of one person who had three scans of her brain. There’s an MRI on the left, which shows some brain cell death.

There’s a PET scan in the middle that shows that one protein called amyloid outside of the brain cell, and the one on the right is a tau PET scan that shows that tau protein or neurofibrillary tangle inside of the brain cell. Now, we can’t get these PET scans in clinic; they’re obtained in research. But you can see the potential in the future if we could. Now, we can also obtain these types of findings from cerebral spinal fluid, or the fluid that bathes our brain. And we collect that through the lumbar punctures. And those of you that are research participants, you know all too well when I’m talking about. [audience chuckling] And the incredible thing is that we can identify these proteins decades before people develop symptoms. So finding the disease is critical for research and for treatment, but understanding it is equally as important. The misconceptions we have can lead to unnecessary suffering, and to a lack of adequate preparation. Alzheimer’s disease is this process of the brain that causes brain cells to die.

Now, brain cell death leads to the thinking changes that we often associate with it. However, it does more than change our memory. It changes our day-to-day function, like walking and eating. It also changes our personality, our mood, our behaviors. It is a disease of people, but specifically the whole person. And the terms we use are important, but they can be quite confusing. The biggest example is that Alzheimer’s disease is not the same thing as dementia. Dementia is an umbrella term that we use to describe what someone is feeling and what family is observing in their loved one. There are many causes of dementia, such as vascular disease, Parkinson’s disease, Lewy Body disease, and of course, Alzheimer’s disease, which is the most common one. So while Alzheimer’s disease is not dementia, it is the most common cause of it.

And Alzheimer’s disease is not going away. It is the sixth leading cause of death in the United States and the only one without a cure or modifying treatment. Currently, there are 5. 8 million Americans living with it. And by 2050, that number is going to increase to 14 million. Now every 65 seconds, someone in the U. S. develops Alzheimer’s disease. And when I started giving these kinds of talks two years ago, that number was 66 seconds. And that doesn’t seem like a significant difference, but for me, that means 20 more people each day are developing this disease.

600 more people each month. 7,200 more people each year. And since I started doing this, 14,400 more people have developed Alzheimer’s disease, in addition to the 65 that, or the ones that develop every 65 seconds. It has to stop. And now between 2000 and 2017, deaths from heart disease decreased by 9%, while deaths from Alzheimer’s disease increased by 145%. One in three seniors dies of Alzheimer’s disease or another cause of dementia. And it kills more than breast cancer and prostate cancer combined. This is the single greatest threat facing the baby boomers and every generation that comes afterwards. And that’s important because there are 77 million boomers alive today. And every day, 10,000 of them are turning 65.

We cannot close our eyes and hope this gets better. But we need to identify the right people at the right time. So let’s say that all three of these people are 67 years old, and they’re all complaining of one year of word finding problems, forgetting people’s names, forgetting the details of conversations from days ago. Now there’s a family history of dementia, which is why they’re overwhelmed and anxious. So they present to their primary care clinic and get a 5 to 10 minute test that shows that there’s a low abnormal score. So do they all have Alzheimer’s disease? Well, the gentleman on the left, he came to my memory clinic, and he had a 60 minute brain test that was normal, no impairments. Instead, we found out that he was depressed. And because he was depressed, he had a hard time sleeping. And because he was having a hard time sleeping, he was taking Benadryl to help him. And Benadryl is a no-no in the geriatric world.

So we addressed all these issues, and he got better. So we diagnosed him with normal aging changes, depression, and medications as a cause for his symptoms. Now, the woman in the middle, she came to the memory clinic, but before she did, she got a brain scan. And that brain scan showed that she had many strokes and a lot of blood vessel disease in her brain. So we diagnosed her with mild cognitive impairment due to vascular disease. And lastly, the woman on the right, she came to the memory clinic, her brain scan, her blood tests were all normal. She underwent the hour-long battery of testing, and it showed an impairment in memory, but everything else looked good. So we diagnosed her with mild cognitive impairment due to Alzheimer’s disease. So for the gentleman on the left, we addressed his lifestyle, his mood, his medications, and his other medical problems, and he got better. But the thing is, we should be doing the exact same thing to the other two people.

Now, the woman with Alzheimer’s disease, I did start an additional medication. We did advanced care planning, and I made referrals to community organizations including our research center. We are not without options, but we need a diagnosis first. So people need the right care at the right time. And right now, it feels worse than 50/50. And what I mean by that is that 50% of people with Alzheimer’s disease are being diagnosed. And of those, 50% actually understand that they have the diagnosis. So we have to do better, which is why it’s so critical that the Wisconsin Alzheimer’s Institute, being led by Dr. Carlsson, is addressing this. We have memory clinics spread across this great state, so that we can actually address and see patients in both rural and urban settings.

But it’s not just the diagnosis of Alzheimer’s that matters. It’s the care that comes with that diagnosis. And I wish the pathway of care was this easy, a straight road forward, but it’s not. It’s more like this, with many forks and twists and unpredictable turns. And that’s why I’m working on the Clinical Pathways program. So that we can have checklists of things to do at each stage of the disease to help prepare, to help navigate the healthcare system that we’re in. And more than that, Dr. Andrea Gilmore-Bykovskyi is gonna talk about care research, the need to address the patients, the family, the caregivers, and all the different settings that they’re going to encounter after they get the diagnosis. So while we’re working on developing meaningful treatments and a cure, there are things that you can do now.

And Dr. Sterling Johnson is gonna comment on the exciting research supporting this. And while it seems like common sense, the foods you eat, the physical activity you get, the sleep you have, and how you handle stress really do matter. When you address those things now, it may help your brain in the future, but it most certainly will help your health today. So I still get the question, “And what’s the point?” “We don’t have a cure, why get a diagnosis?” To that I say the Wisconsin Idea, there is power in information, in knowing what is happening to you. What is the cause for your experience? It matters to my patients; it mattered to my father. Being able to process what was, or being able to prepare for what was about to happen to him mattered to us. And it’s– preparation isn’t just preparing for the bad things, it’s living. It’s prioritizing the things that really do matter with the time that you do have. Now, getting good medical care from our memory clinic really did matter, but also having a team outside of clinic and having a strong social network mattered too. Now, being a part of research has always been important to our family.

I only wish we could have been a part of the research that Dr. Gilmore-Bykovskyi is gonna talk about next, because it values the family and the caregiver in a very special way. There’s so much more to do here. And I’m glad all of you are here to learn what comes next. Thank you. [audience applauding]

– Thank you, Dr. Chin. So it’s a true pleasure to introduce our next speaker, Dr. Andrea Gilmore-Bykovskyi. Dr. Gilmore-Bykovskyi is an assistant professor at UW-Madison. And she received her research training right at the ADRC here. She’s among one of very few recipients of the prestigious award from the NIH called the Beeson Career Development Award. This award is given to only six to eight scientists in the United States each year, and she was one of the successful recipients a couple of years ago. So she’s using those resources to do research, and the research focus is on how best to manage symptoms of the disease, and how best to make dementia care equitable for people of all races and ethnicities. And as you can imagine, these are pivotal layers of research in Alzheimer’s disease, and she’s a national authority. It’s a true pleasure to invite Dr. Gilmore-Bykovskyi to make her presentation. [audience applauding]

– Good evening, I’m really pleased to have this opportunity to be here with all of you at Mini Med to talk about a topic that I know I and many others have dedicated my clinical and research careers to. And that is understanding how we can extend this critically important science of understanding the underlying causes and potentially effective treatments for Alzheimer’s disease to also understanding how we can meet the here and now needs of people experiencing this condition and the caregivers that are going along a parallel journey with them very often.

Here, what we see our pictures of our former governor of Wisconsin, Martin Schreiber. Some of you may have seen him speak publicly. He’s become a national advocate and a real pioneer for speaking on behalf of family caregivers. He’s pictured here with his wife, Elaine, who has been living for some time with dementia. Among the very many wise words that former governor Schreiber has shared with us as a part of his journey as an Alzheimer’s disease caregiver, this sentiment, I think really hits home for me. What he tells us is that, “As my wife went through the stages of Alzheimer’s, “I realized there were things I didn’t know soon enough. “One thing that is worse than Alzheimer’s “is ignorance of the disease. “Not about how the brain works, “but the ignorance of caregivers not understanding it. “The converse is rather than worrying “about the storm to pass, “learning how to dance in the rain. ” I think his words speak for themselves here, and I’m gonna be talking about some of the things we’re doing at the University of Wisconsin and through the School of Medicine and Public Health to address this sentiment in real time.

But in order to do that, we first have to have an understanding of what the face of Alzheimer’s caregiving looks like in our country, and this is what we know right now. Currently, there are more than 16 million individuals who are caring for someone with Alzheimer’s or a related form of dementia. I’m sure many of us have experienced or are experiencing this currently. Collectively, these individuals leverage a phenomenal 17. 5 billion hours in unpaid effort in the work that they do to meet the needs of people living with Alzheimer’s and dementia. About 23% of them are in the later stages of their life. About two thirds are women. And we know that about a quarter are sandwich generation caregivers. So those lucky folks that have those dependent children at home and are also working to support their parents. So this tells us that different caregivers likely have different needs.

That’s one good piece of information that we need to have in order to know scientifically how best to proceed. Next, we need to ask ourselves what caregiving looks like, what is the daily work, what’s the daily experience? There are some obvious tasks that might come to mind: managing medications, helping somebody get to their medical visits, maybe visiting them or advocating on their behalf, which we know if you may have Alzheimer’s or dementia becomes challenging over time. There’s also a host of what I call invisible work. That although it’s more subtle and less obvious, is nonetheless important and critical. This includes coordinating often complex networks of other caregivers, including coordination with different specialty providers. Perhaps you see a cardiologist, perhaps there’s a diabetes nurse working to assemble all of this information in real time. You may find yourself taking over legal and financial matters, and working to attend the importance of environment. As people progress with Alzheimer’s and dementia, we need to make sure that the environments they’re in are safe and secure for them, as their thinking may be not what it was some years ago. And the very important work of offering companionship, providing meaning, and attaining to some of those symptoms that Dr. Chin had mentioned.

The changes someone might have in their behavior, or their personality or their mood. After that, we have to, I think, really anchor ourselves in what former Governor Martin Schreiber was telling us: Understanding, with great clarity, the significance of the experience of being a caregiver for someone with Alzheimer’s. And also the consequences of that caregiving role. One thing that we’re learning from emerging research is that the vast majority of caregivers, should you give them the opportunity to tell you, will share various rewards that they have encountered throughout their journey. And I think this is important to take time to appreciate that. These rewards often revolve around understanding something about someone who’s been important to you that you didn’t previously understand, strengthening a relationship you maybe wouldn’t have otherwise strengthened, and discovering new things about yourself as an individual. However, amidst these rewards, we know that there are also important consequences for both mental and physical health that caregivers experience at disproportionately high rates as compared to those that aren’t in a similar caregiving role. About 60% state that their stress level is high or very high; we are gonna be hearing about stress as an important thing for us to pay attention to for our own brain health. 39% state they feel depressed, as compared to 17% of the general population. And nearly 60% feel that they’re on duty 24/7 to meet the needs of somebody living with Alzheimer’s.

And lastly, about 43% have difficulty taking care of and maintaining their own medical or health needs. There’s a simple takeaway, it may not be simple in reality, but it’s a message that I hope we can take with us, repeat to ourselves, and repeat to others that we encounter. The message is “Don’t go it alone. ” We have sufficient evidence, decades at this point, to demonstrate to us that working to be an Alzheimer’s caregiver without the sufficient supports and resources has an impact on mental and physical well-being. All of this challenges us to ask ourselves, “How do we respond?” What does the clinician do and what does the scientist do, and what are we doing at Wisconsin? And I’m really excited to share that I think we have a robust, very innovative response to the needs of Alzheimer’s disease caregivers. We here at the University of Wisconsin have established and are leading the first national initiative focused specifically on care and caregiving research through the Alzheimer’s Disease Research Center. We are the first of those 30 centers mentioned by Dr. Asthana that has dedicated core resources and scientific attention to the needs of people who are living with the disease right here, right now, or who are caregiving. And we know that there are many of us. Some of our first priorities in this initiative, and these are other scientists that bring with them expertise from engineering, from speech language pathology, from medicine, and from community engagement.

We’re focusing on caregiver education and support, the development of new and emerging technologies to support caregivers in these roles, and also to support monitoring home environments so that some of that work can be alleviated from the caregiver. We are fortunate to be aided in this work by the Wisconsin Alzheimer’s Institute Dementia Diagnostic Clinic Network that Dr. Chin introduced us to. This is a robust infrastructure that we will leverage as we go forward. There are 38 memory clinics throughout the state where primary care providers are trained by experts here at UW, where we have medical students and other clinicians also getting this cutting edge training, and having ready access to clinical trial opportunities, including emerging opportunities for care research. And one of the most important benefits, I think, of this network, and what’s very exciting is ensuring that the things that develop here on this campus extend far beyond and throughout every area of our state. One of our first questions and priorities through our care research efforts are developing new technologies. And I wanna talk a little bit about what that looks like. This is something as simple as an application that you might have on your smartphone, that we now find we can’t put down. And we’re carrying it with us everywhere, although there is a side effect of this, which is it’s accessible and available at various points in time.

So working to provide a platform that we are designing in close collaboration with people living with a condition and their caregivers, so that they can seamlessly share information about the tasks and the work they’re doing, so we can help them identify when a caregiver in that network might be experiencing too much strain and burden, and help them think of strategies to redistribute some of the work associated with caregiving in real time. Because we know that this is something that affects many of us personally, we feel it’s paramount that we also talk a little bit about some practicalities right here, right now. If this is something we might be facing, or we might face in the future, what do we need to know? What does best evidence tell us? And there are three real takeaways here. The first is education. You all can give yourselves a little check in your box for that one tonight. But we need to really work to take advantage of opportunities to learn about brain health for ourselves and for others. We’re gonna learn from Dr. Johnson about some really exciting new research that indicates that there are some potentially modifiable lifestyle choices that we can make that may modify our own risk. And these are the types of things that we wanna encourage others who are in their 30s and in their 40s to learn about early and often. Support.

This is really hard. I know I’m bad at it, but asking for help and accepting it when it’s offered. This is one of the number one things that if we find ourselves in a caregiving role, we can do to shift that trajectory of health consequences for ourselves so we can stay in the game for the person that we care for and love. And the last has to do with change, yet another uncomfortable predicament. Change is hard for all of us. One thing we know about Alzheimer’s disease is there’s a somewhat predictable series of changes that somebody might experience with their cognition. We know they will have losses and changes, and they will become worse over time, and they’re often gradual. So we can anticipate that the things we’re doing now might need to look different in a year. And just thinking ahead a year or two can be really helpful for the types of supports and resources we might engage. And I always like to take a moment to talk about the person who’s experiencing this process.

We know now from quite a bit of research that people living with Alzheimer’s disease not only need, but they benefit substantially from care and supports that keep them socially engaged, from things that provide them meaning in their life, that they’re able to carry on conversations, enjoy music, enjoy parks, enjoy bike rides; I love that picture of Dr. Chin and his father. These are things we need to work to keep going as much as we can to maximize every day and every moment that’s afforded to us. And I wanna close by just briefly sharing a couple of resources. We’re very fortunate here to have not only resources through UW and SMPH, but also in Dane County in general. If this is something you find yourself thinking, “Maybe it’s time for me to seek out some resources,” these are some really great starting points that we recommend connecting with. And I thank you so much for your time and the opportunity to speak with you this evening. [audience applauding]

– Thank you, Dr. Gilmore-Bykovskyi. One of the facts I want to share with you all and truly a proud moment for all of us collectively, is that three of four speakers tonight have trained right here at UW-Madison and at the Alzheimer’s program.

At this early stage of their career, they’ve become nationally renowned researchers. Just imagine what they will become and do for the field of Alzheimer’s and for SMPH and UW 10 years down the road. And I think this is what institutions like UW do. They train the next generation of scientists and leaders, and they keep them here so that they can help the state, they can help resolve the disease, and really produce some amazing results. So the next speaker is Dr. Cynthia Carlsson. Dr. Carlsson is the, is the Lou Holland endowed professor in Alzheimer’s research. She’s also the director of the Wisconsin Alzheimer’s Institute. I remember when Dr. Carlsson was a fellow in geriatric medicine here, and I came here from University of Washington 18 years ago, and she came to my office and said, “Dr. Asthana, could I work with you in Alzheimer’s’ disease?” I said, “Absolutely. ” And you see what she has done 10 years down the road. This is truly spectacular. Dr. Carlsson’s research is focused on vascular risk factors of Alzheimer’s diseases, things like diseases like high blood pressure, diabetes, how do they increase the risk for Alzheimer’s disease? And she is internationally renowned for her research and leadership for the field of Alzheimer’s disease. It’s a true pleasure to invite her to make her presentation. [audience applauding]

– Thank you, Dr. Asthana. It’s a thrill to be here. And thank you so much for each of you taking time to be here tonight and to learn about the work we’re doing, the advances in Alzheimer’s disease. I know that there are a lot of people here, there are research participants, there are families and patients from our clinics who are here. We have members from our Initiative to End Alzheimer’s Disease board. So thank each of you for being here tonight. We’ve shared several stories tonight, and as Dr. Asthana mentioned, the Lou Holland family have been a great partner with us in again, I’m honored to carry his dad’s name with my title. Mr. Holland was a Badger football star here at UW. He had a successful career in business, and unfortunately passed away from Alzheimer’s disease several years ago. And his family has been amazing champions for helping us to find new ways to identify this disease earlier and help move our program along.

So he’s one of the stories, and there’s more stories from our board and other people on our website at Memories Matter. So I encourage you to look at that as well. So here’s my story. So the reason I’m here, my grandmother developed what they thought was Alzheimer’s disease when she was in her early 70s. This is a picture of her when she was at her 50th wedding anniversary. And unfortunately, she did not really know many of the people that she was there with. She was celebrating this great occasion and wasn’t really sure what was going on at that situation. That really motivated me to want to go into geriatrics and then to do Alzheimer’s disease research. Watching her go through this, my grandfather care for her. So again, when we think about, the other reason I bring up this picture is that when we think about treatments for Alzheimer’s disease, the topic of my presentation, we really need to think about two things.

So one, are what are some of the symptoms that we’re seeing in the person, but also, what is going on in the brain of that person? So Dr. Chin has introduced the concept of these plaques and tangles that we know are related to Alzheimer’s disease. And so again, in our work, we’re really trying to look at both the person, but also trying to understand what the underlying cause of those changes are. So our current medicines really work to reduce the symptoms of Alzheimer’s disease, but don’t really change the underlying disease itself. And so this is a graph or kind of a picture, that if you look at the thinking abilities here, see if I can get my mouse to work here. So for these thinking abilities over time, you can see that there’s a little bit of a decline with normal aging. It may take us longer to learn new information. It may take us longer to recall information, but we should be able to maintain our day-to-day function, do the things that we normally do. However, when we develop, we’re heading towards a diagnosis of dementia due to Alzheimer’s disease here, there’s a phase we go through that we call mild cognitive impairment, where someone had some problems on their cognitive tests. But usually they can make up for it by making lists, using maps, sticking to those reminder notes a little bit more closely.

But once someone can’t even compensate, despite those cues, that’s when we say that someone has dementia due to Alzheimer’s disease. So again, this is about the time in between mild cognitive impairment and dementia when they’re coming into the clinic to see us. So by the time we start therapies, the other important part of this picture, as you can see, there’s all these accumulating Alzheimer’s disease brain changes that have been probably going on for decades already. So by the time they’re coming to our clinic and they have symptoms, they’ve had these changes for decades. So when we start our therapies, again, you can see that it slows the decline, it slows the symptoms, but it’s not really getting someone back up to where they were before. And why is that? So again, we have two groups of medicines that we use now widely in clinical practice. The first group is listed here. So you may have seen ads or different people talk about “I’m on Donepezil,” or Aricept is the other name. Rivastigmine, Galantamine, so that’s kind of one group. And then another group called Memantine or Namenda.

The key thing about these medicines though, if we go back to that picture, again, what’s happening in the brain. Again, we know there are these plaques and tangles. So these plaques outside the nerve cells, these tangles are inside the nerve cells. But what these medicines do is chiefly to help these dying nerve cells communicate with each other by improving the chemical signal across the nerves, but it’s not really doing anything to the underlying cause. So it’s not getting rid of those amyloid plaques. It’s not getting rid of those tau tangles inside the nerve cells. So that’s why we see the slowing of the symptoms, but it’s not really getting rid of the disease itself. The frustrating part to me, so again, not only as a granddaughter of someone with the disease, but as a clinician who sees patients every week with this disease, there have been no new medications for Alzheimer’s disease for 16 years. There’s new combinations. So you can take it as a single pill or patch, there’s all kinds of different combinations, but not a single new FDA-approved medication for 16 years.

So that’s why we’re so thankful to be a part of the School of Medicine and Public Health here at UW. Because our medical school is really investing and trying to develop our clinical trials program across all diseases, but especially within our Alzheimer’s disease field. And so within this, what we’re hoping to do is to develop more clinical trials so we can compare what, how new treatments work compared to standard of care. So one thing I wanna point out when we think about clinical trials, is that we always have to have a comparison group for clinical trials. So what are those? So then usually, a clinical trial’s where you’re comparing someone on standard of care therapy to a new therapy on top of standard of care. So again, if you saw this person and they were started on, let’s say they started out on Donepezil here. If you just looked at that person by themselves, you’d say, “Well, they’re getting worse, “so the medicine’s not working. ” But if you can see where they’d be without that medicine, that red line, then you’d say, “Oh, the medicine is helping to some extent. ” So with clinical trials, we always need those comparison groups so we can see if there’s an improvement over what the standard of care is. So for example, let’s say we find a therapy that we could start earlier, identify the disease earlier, people got into the clinics earlier, and then maybe we could delay that progression so that they had more function.

And even more optimally, what if we could identify cognitive changes or brain changes before people developed memory symptoms at all? That’s what we’re working toward. And that’s what our program’s really focused on. And Dr. Johnson, after I speak, will talk some more about these new ways we can identify these brain changes early to help protect our brain early on. So in our Alzheimer’s Disease Research Center, again, we’re taking that approach where we’re looking at the person and also on the brain changes. So again, here’s one of our outreach specialists, Susie, who’s interviewing a person in our study. She’s gonna ask her questions about how her life is doing, how she’s functioning in a day-to-day basis, what she eats, what her medicines are, and also do some thinking tests with her to check different thinking abilities. And then we also have a participant here who I can’t, he’s anonymous, I won’t mention his name to protect his privacy. [audience chuckling] But he had a brain scan done, and his little buddy in the scanner there too. But again, this scan can show if he’s got amyloid buildup in his brain.

We also can look at certain spinal fluid tests. So again, this person, I’ll just use initials BB. BB came in and he had some spinal fluid tests. So again, we’re able to look, talk to the person and to check their brain health to see what kind of brain changes. Is there amyloid there, are there tau changes, or is there inflammation or other new changes that we haven’t even identified yet. So that’s extremely important. So at UW, we’re really taking an approach where we’re looking at a variety of things. So one is, how can we use some medicines that fight against that amyloid that we talked about? How can we find some other therapies that maybe look at exercise or other health factors? We also have some studies that look at our gut health. So microbiome supplements. Looking at studies like fish oil, which might help improve our blood flow to the brain.

So we can see that we have a variety of studies that are looking at different types of things that could contribute, and also across diseases. So people who have healthy memory, people who have mild cognitive impairment, and people with dementia. A lot of people will ask me afterwards, “Well, how do I get involved in a clinical trial?” Again, Alzheimer’s is a very, very human disease. It’s hard to replicate it in animal models. So clinical trials with people are really, really important. So there’s several websites here. So our Alzheimer’s Center has a website showing open studies for our clinical trials. There’s a National Institute of Health has a website for clinical trials. And the Alzheimer’s Association also has a website with information on clinical trials. As I went to the National Institute of Health website to take a screenshot to show you what that might look like, I saw this picture of this wonderful person.

I don’t know if anyone in the room knows her. But this Keretha, she’s one of our research participants on the NIA website. And I can say her name because she has a full story on the NIA website that tells her story of why she chose to be involved in Alzheimer’s prevention research. So I encourage you to look that up, go on the NIA website and hear Keretha’s story. So again, in conclusion, again the new treatment trials are really gonna focus on both what changes we see in the person and on the underlying brain changes. UW investigators are really looking at a variety of approaches. So again, against amyloid and other factors. And then as the Alzheimer’s Association has really pushed, the first person to be cured of Alzheimer’s disease will be part of a clinical trial. So really getting us to think more about being engaged in clinical trials. So I’ll stop there, and thank you so much for being here this evening. [audience applauding]

– Thank you, Dr. Carlsson. Our next presentation is by Dr. Sterling Johnson. Dr. Johnson is the associate director of the Alzheimer’s center. He’s also the Gene Finley endowed professor of Alzheimer’s research. Dr. Johnson is a world-renowned scientist in imaging research in Alzheimer’s disease, and also the cerebral spinal fluid biomarkers of Alzheimer’s disease. Dr. Johnson was the first recruit I brought in here into our Alzheimer’s program; he came from Arizona. And he is also the director of the famous RAP study. Raise your hands if any one of you is involved with the RAP study. There you go, some of you are actually part of the study, RAP– [audience applauding] Thank you for being a part of the study. RAP is the largest and the longest ongoing study of its kind in the world. And it includes 1,500 middle-aged children of patients with Alzheimer’s disease who are at risk for the disease. And Dr. Johnson and his crew has published hundreds of papers, trying to tell the field that there are certain changes that take place in the brain that you can detect through brain imaging, special PET and the MRI scans, at a stage when someone has no symptoms. Now, imagine what a great thing that is because as we come up with treatments, we can use those treatments to stop the disease when someone has no symptoms. That will be an amazing outcome.

That’s where we are targeting here at Alzheimer’s Center. The research that is being done here is truly world class; it is world-renowned. So without any further delay, I would like to invite Dr. Johnson to talk about what are the ways we can diagnose the disease early at an asymptomatic stage, and also what are the ways we can prevent it? Dr. Johnson. [audience applauding]

– Good evening, everybody. Can you hear me okay? Great, well, thank you Dr. Asthana for the introduction. I’ve really learned a lot from Dr. Asthana. He’s been a mentor and friend, and a co-author on many of those papers. Most of those papers as well as my co-presenters tonight. I wanna thank them all. And I also wanna thank you, especially those of you who’ve been in research, who’ve been part of our ADRC or our RAP study. A lot of what you’ve heard tonight so far around how this disease forms is from studies like RAP. And in fact, RAP has been the basis for many of the findings that we now talk about and consider as a given. So thank you for being in the studies. We are learning from you, just like you’re learning from us tonight. The goal of our studies, especially in this area of early detection, is to get to this disease before the symptoms appear. And this is so important, because how else are we gonna prevent it until we can understand it and have clarity about what it is? Then we can understand what the lifestyle factors and health behaviors and genetics, all those things that might help us understand how we can slow the disease down or eventually prevent it from occurring.

This is Alzheimer’s disease under a microscope, and this is way too late to understand this disease. This is after a person has passed away. We can certainly learn a lot from the brain. I don’t wanna say that this isn’t valuable. This is incredibly valuable to us. But we need to be able to diagnose this disease and understand it when the disease is barely emerging in mid-life. And these are the kinds of scans we can use, an amyloid scan or a tau scan, these two major proteins involved in Alzheimer’s disease. This is how we can do it. And with these technologies, we can understand when this disease is starting, how fast it’s progressing, and what the gap is between its biology and its symptoms. So you can think of it this way, that Alzheimer’s begins with the amyloid plaques.

And after that, come the tangles. And we still don’t have a solid timeframe for that gap between the amyloid plaques and tangles; we need more research. We do know that after that, that we lose our nerve cells. And we’ve seen some pictures of nerve cells tonight, and they are very complex structures. It’s not just a circular cell, it’s a cell with lots of branches and offshoots, and they form connections to each other. And those connections are called synapses. And those synapses are how they communicate. And this is critical for what I’m about to tell you. After the plaques and tangles and the nerve cell loss, depending on how many synapses and connections we have, then come the the mild cognitive impairment stage and the dementia stages. These are, this is kind of characteristic of the way things go, the biology appears first and then the symptoms.

But when does dementia develop relative to the onset? It’s about 20 years after the plaques first appear in the brain. And again, we know this because of studies like RAP, and in fact, we’ve confirmed this in the RAP study, that it’s about 20 years. So this is important. This means that we have that window of time to see if we can prevent the symptoms from ever emerging. So what we’ve learned so far tonight, in this session, is that this disease begins many years before its symptoms. We now have these tools, imaging tools and spinal fluid tools, to understand how and when it develops. And it’s only with these kinds of techniques that have been validated and proven here at the university and several other academic institutions that we can now use these and apply these techniques to understand the early time course of this disease so that we can figure out how to prevent it. So let me shift now to what these kinds of tools have told us about some prevention concepts. And I’ve listed some concepts here around prevention, you’ve probably seen many of these in the media, on TV, on your news feeds, on your phone, or in other places. Hypertension, physical activity, sleep, diet, your stress level, even your neighborhood, how you stay cognitively and socially engaged.

These are all things that are actively being studied at our university, as well as in many other places to see if we can slow this disease down. And we’ve already heard about drug treatments, and these are still a mainstay in an active– incredibly important way of understanding prevention. But this is just a partial list. There’s many other things we can add to this list. But we know that all of these things improve brain health. What we need to know is, do they help with Alzheimer’s disease? So I’m gonna talk about a few of these now. First, let me talk about hypertension or blood pressure control. We know blood pressure control is good for the heart. And most of you have heard the saying, “If it’s good for your heart, it’s good for your brain. ” And that’s exactly the case with blood pressure control.

We know that blood pressure control improves brain health, reduces your risk of stroke, reduces strokes, it improves blood flow to your brain. It helps the brain stay more connected with itself, these nerve cells can talk to each other. And this is critical. Now, does blood pressure help reduce Alzheimer’s disease risk? There’s evidence to suggest that there’s possibly a connection here. And that evidence is that people with better blood pressure control have lower rates of conversion to dementia. And this is important also, slower rates of cognitive decline over time. So blood pressure control is an important one. What about physical activity? We’ve heard tonight about physical activity and brain health, and this is indeed an important thing for brain health. Something to note from these two individuals who are bike riding, they’re smiling and they’re doing something, they’re doing physical activity that they love to do, and that’s an important consideration when you’re selecting the physical activity that you want to do. Make sure it’s something you like to do and something that you’ll sustain doing over time.

So does this improve brain health? I think we all understand that it does. It improves blood flow to the brain, helps the brain grow new synapses and new connections within itself. And it’s very good. Does it slow Alzheimer’s? Well, again, there’s correlational evidence. There’s no clinical trials that suggest that it cures Alzheimer’s. But there are some correlational studies that are important that suggests that this will lower the rate of progression of our cognitive symptoms. And let’s go on to sleep. This is an important one, perhaps a challenging one for most of us. Does this impact Alzheimer’s disease and brain health? Well, let’s talk about brain health first, yes, of course, in multiple ways. The better we sleep, the better state of health that our brain is in.

This helps the brain process information from the day, so our memories are consolidated and improved during sleep. It’s a time where the brain can get rid of some of the metabolites that it’s used during the day and kind of drain itself of used nutrients and so forth. And it’s also a way of regulating hormones and other important functions. And we know that people who sleep better have slightly larger brains in some parts of their brain, and also better connections between the neurons in the brain. Does it slow Alzheimer’s? Well, again, there’s correlational evidence that there’s a connection here. That better sleep, especially in people who are starting to experience symptoms, will have a slower course over time. I wanna stress how these are all correlational, for the most part, about preventing or slowing Alzheimer’s. But the evidence is consistent over studies, and this is great to know. What about our diet? This is an important one for us. Of course, diet is important for our brain.

A poor diet results in a number of other health problems, including diabetes and obesity and all the things that go with those. The Mediterranean diet has been one that’s been studied mostly, most with with Alzheimer’s disease. And this is a diet consisting of a large amount of grains and vegetables and fruits and healthy fats, like olive oil and avocado oil. And less on the meats and certainly much less on the sweets. I think cutting out the sweets from our diet is probably the number one thing you can do to improve your diet, and then eat more veggies. So does this improve brain health? Yes, of course, we all know that it does. Better energy, lower risk of stroke and diabetes, better memory function, and other aspects of cognition. This is a keeper. Does it slow the amyloid plaques and tangles? It doesn’t slow the plaques and tangles that we know about. But it is associated with a healthier brain volume, which probably means more connections in the brain.

And it’s also associated with better cognition. So these are all important anchors that we’re holding on to about the effect of these behavioral health factors. And these are all things that we can do. We can improve our blood pressure, we can improve our physical activity and our sleep and our diet, and all of these things will give your brain a little buffer, a little more resilience against any impending things that might come your way. Whether it be Alzheimer’s disease or stroke down the road or some other major disease. So in summary, I just wanna say it’s these new tools that have made it possible for us to understand and peer into the brain before a person has passed away to understand the life course of this disease. And we know from these kinds of techniques that we can now study prevention. We can understand this preclinical phase of the disease. A healthy lifestyle is good for the brain, just like it’s good for the heart, and we want to encourage you to do that. And we also want to give you some cautious optimism tonight that a healthy lifestyle may slow the effects of Alzheimer’s disease.

We definitely do need more work. It’s difficult to do clinical trials with lifestyle because you gotta do them for a whole long time, longer than a than a three-year clinical trial, probably a decade or more to really understand this, from a scientific effect size way of understanding whether there’s a significant difference between people who engage in these behaviors and people who don’t. But we can see fairly immediate effects in the clinic and in our daily lives and our energy level, in our outlook and our mood. All of these things are improved fairly rapidly when we start engaging in these things. So we’re cautiously optimistic. This is an exciting time to be in Alzheimer’s disease research. The findings are coming out so fast and furious, and this field is rapidly changing. I think we’re poised to make some important discoveries about prevention and treatment that are gonna change the face of Alzheimer’s disease. So I’ll stop there and thank you for your attention. [audience applauding]

– Rebecca: Can we have all of our speakers come up and join us?

– By the way, that was fantastic. I just learned so much, another round of applause for these people. [audience applauding] So while they’re walking up, I have a question, should I get a brain scan now, anticipating this might be plaques, and then maybe we could do something about it?

– Sterling: Should you get a brain scan now? I think if you’re in research, you should get one now. But we, it’s without knowing how, what we would do with this clinically without having that silver bullet of an effective treatment, it’s difficult to advise our patients to do that. I don’t know if any of our clinicians have advice on that too.

– Cynthia: I agree, we always think about is this gonna change my management by getting a scan? Is it gonna change my management? We’re still gonna recommend that you get your blood pressure controlled. And that’s you, if you wanna take on one point today and wanna do one thing for yourself, your family members, control your blood pressure. I think is probably the most important thing for protecting brain health right now. So either way, you’re gonna control your blood pressure, try to exercise more, try to eat more vegetables, talk with your doctor about getting off of medicines; it can have negative effects in your thinking. So some of it will be the same that a brain scan may not help alter.

– While we’re waiting to collect more, waiting to collect more questions, how about a question about family history? We hear a lot about that. So what’s the data there?

– Sterling: I guess I can talk about that one too. Family history increases a person’s risk of Alzheimer’s disease. If you think about each of us at age 65, we have about a 10 or 12% risk of getting Alzheimer’s disease in our future after age 65. If you have a parent with Alzheimer’s disease, it increases your risk. There’s some suggestion that it might double your risk from 10% up to about 20% lifetime risk after age 65. Yeah, some of that is probably, most of that is probably related to one gene. And we didn’t talk about this gene a lot tonight. It’s called the APOE gene. And that’s an important risk factor for Alzheimer’s.

– Sanjay: Yeah, just as a follow up to what Dr. Johnson said, clearly, family history does increase the risk. But as you know, that none of these risk factors are 100% that one is going to get the disease. So in fact, even if you have multiple risk factors, you can still reduce the risk for the disease by following all the good things you heard tonight. Healthy lifestyle, healthy diet, exercise, controlling your disease and high blood pressure, heart disease, high cholesterol, those kind of things, will significantly reduce your risk for Alzheimer’s disease. And I think that’s a very positive outcome of years of research here and across the country.

– Laurel: Dr. Carlsson, should I take fish oil tablets? That’s number one. And then number two, are there any other no-no medications besides Benadryl?

– Cynthia: As far as taking fish oil tablets, so what I recommend for all of my patients, my family members of patients, is that you, whether it be your blood pressure medicine, your cholesterol medicine, fish oil, that right now you work with your doctor on following standard heart guidelines. And there are a lot of strong evidence about using statin medicines, blood pressure medicines, fish oil for certain people at certain cardiovascular risk. So I wouldn’t necessarily go out and take fish oil right now by yourself, but talk with your doctor and ask your doctor, “Should I be taking fish oil?” Either to help lower your cholesterol or to protect against heart disease health.

Hopefully, it’ll also help with Alzheimer’s risk. As far as other no-no medicines, there are a lot of groups of medicines like Benadryl, things that fight against allergies, those medicines can have negative effects on your thinking, pain medications, like opioid pain medicines can have negative effects. Gabapentin and some other medicines that help with nerve pain. But again, as we talk about in our clinics, each person is a whole person. And so if somebody is in awful pain because they’re on a pain medication and they stopped it to protect their memory, then they’re not gonna sleep, they’re gonna be miserable. So really, for all of these things, you need to talk with your clinician and think about, “What’s most important to me?” Getting good pain control and good sleep and being a little more groggy in my thinking, or else getting off of that? So again, it’s always a balance.

– What is the first step if you know someone needs help?

– Andrea: That’s such a wonderful question. I think the most logical first step would be to reach out to your primary care provider and to pursue some of the testing that we heard about tonight. There are standardized cognitive assessments and evaluations that would help to clarify what might be going on. We know that there are changes that we have with aging, and sometimes we may have changes and they may just be a normal part of aging for us.

Or there could be other modifiable things that are going on, we had the example of depression, which is a very common thing that we see that can cause some of these changes in thinking and make things cloudy, but it’s treatable. Did you want to add anything?

– Nathaniel: One of the other things I would say is that you, at some point, you’re probably gonna wanna talk to that person and express your concern and your worry about what they might be experiencing. And sometimes it’s nice to have particular examples, because when someone brings up that you might be having a memory change, you’re gonna be defensive, I think that’s just a natural response. And it’s not that the person has the disease. It’s just, you’re feeling uncomfortable and vulnerable at that point. And so having particular instances, and not that I want you to use those as pieces of evidence to force them to do something, but it might be helpful for a context for a person to realize, “Oh, yes, that is true. “I did forget that these things happened multiple times. ”

– Laurel: Okay, does Prevagen, which is an over-the-counter drug, help at all, or is it just an advertising ploy?

– Sanjay: I know it’s a very popular thing on the, over the counter, a lot of people use it. To the best, best of my knowledge, there’s no evidence that Prevagen helps with memory or Alzheimer’s disease. So frankly, if I was you, I would not spend that money buying Prevagen, there is no scientific evidence that it helps in any way.

– Is age 70 too late to have a brain scan and slow the decline of brain health that leads to dementia? And you have to be a part of a study, or should your primary care doctor help determine if you have an inclination for Alzheimer’s?

– Sterling: These experimental brain scans that we talked about tonight are just that they’re part of research and they’re not necessarily available clinically. That is changing. There’s three amyloid scans that are approved by the FDA now, and they may be available to your doctor in the future. Right now, that you have to pay out of pocket for those ’cause Medicare does not pay, none of the insurance companies pay. And they cost over $5,000 for each of these scans. So it’s, they’re not really available clinically yet. But that is changing. There’s several studies underway, and policymakers committees that are convening to see if they can change this.

– Laurel: Does long-term use of statins have an effect on the onset of Alzheimer’s?

– Cynthia: So this is one area I’ve studied is the effect of statins on Alzheimer’s risk and all, and statins, probably, if anything, protect our brains for sure from strokes. Statins may have a way to help protect our brains from the onset of Alzheimer’s, but it’s not proven yet.

So we’ve done some studies here that show that statins seem to improve blood flow to the brain, may improve some thinking tests, but not yet proven that they are helpful for preventing Alzheimer’s. But again, just as I do with other cardiovascular recommendations, talk with your doctor about whether you should be on a statin. I would never recommend someone stopping a statin because they’re concerned it’s gonna contribute to Alzheimer’s, there’s no evidence along those lines. But there may be a benefit. But chiefly, if you protect your brain against stroke, that will also help your cognition. If you protect your heart against a heart attack, that will also help protect your cognition.

– Lots of Benadryl questions here, Dr. Chin. So why is Benadryl bad in geriatric population and many over-the-counter sleep aids contain Benadryl; should they be banned?

– Well, that second question. I’m not gonna speak to the politics of it. But so Benadryl, how it works is it’s called an anticholinergic. So you’re gonna hear that or read about that a lot. And choline is that signal that Dr. Carlsson was talking about that one brain cell is trying to communicate to the other and tell you to remember something or pay attention. And so this drug actually removes that choline signal from the brain, which is why we often will feel sedated or sleepy when we take Benadryl. That is actually the removal of that communication signal. And so our pharmacists have done a wonderful job in the past 5 to 10 years, showing that extensive use, not a little use, but extensive use of this drug over a lifetime does increase risk for developing brain changes and cognitive impairment. And so it’s not– I will tell my patients if you’re having an allergic reaction, yes, please go ahead and use Benadryl. But the thing that we see so often is that people will take something once and then they just keep taking it forever, and it’s not the person’s fault or even the doctor’s fault, it’s just something that happens. And so it’s one of those things where I don’t want people to be on Tylenol PM or Advil PM, or Benadryl just to help them sleep.

We have other things that we can do instead of the medication. And so anything that has a anticholinergic property in a way has, it increases our risk for developing changes later on. But if you’re taking it infrequently it’s not that, one or two uses is gonna be the problem.

– Sanjay: Could I just add, and that’s a very important question clinically, of course, not only Benadryl has anticholinergic activity, but actually there are many other medications that have anticholinergic activity like antidepressants, or medication we use to treat Parkinson disease. So when someone is taking those medications for those diseases, it is not advisable to stop them, you should always consult your doctor to see what is the risk-benefit ratio of continuing medications, a number of them that have anticholinergic effects because they will be essential for management of the disease. So this is an area that you should always consult with a doctor before you stop it yourself and no one advises you to do that.

– Cynthia: One additional point I think, to Dr. Chin’s point to the Tylenol PM and Advil PM, it’s not the Tylenol or the Advil that is a problem, it’s the PM parts that, which is the Benadryl. So if you’ve talked with your doctor and Tylenol is fine for you to take, you can take Tylenol, just take off the PM part. Or if you’re on Advil or some other ibuprofen, and they said that’s fine for you to take, just take off the PM part. So just to point out it’s not those agents, it’s the Benadryl part.

– Laurel: What are the one or two major mistakes made by caregivers?

– Andrea: Well, I would have a word choice revision. I think it’s, we learn a tremendous amount from caregivers, thinking of people that have gone, in some instances, decades with this, the task ahead of them. I think that challenges that people often face or that they’re often unprepared for some of the changes they might experience. So perhaps it’s seeking or connecting with the education that may help you understand the changes we see in someone we love. It’s, of course, very different if I’m a nurse, or there’s a physician, and you’re working with a patient, and this is my spouse, or this is my mom. These are people we have really deep relationships with. And we interpret their behaviors differently because we know them, why are you doing that? And the education to help us understand how their behavior links to the pathology in the brain can really help a caregiver respond differently. And I think the second thing I alluded to already, which was accepting help, it can be so hard. We’re logically protective of the people we love, but being able to recognize that there will come a point in this particular disease journey unfortunately, where we need to elicit other services and supports. And waiting too long for that, I think is a challenge that many people face.

– Rebecca: This is a good one. Do games such as Sudoku, crossword puzzles, Candy Crush, Renren, I don’t know that one, help prevent disease?

– Nathaniel: So I always think any sort of brain activity is a good activity. Now, the science doesn’t show that a particular thing like Sudoku is going to improve your memory. But we are very capable creatures. And so a particular skill such as word search can improve our language perhaps in the word search game itself. We just don’t see that translating to the other many parts of the brain. So I don’t want that to be discouraging because I still think overall for the brain health and for keeping those brain cells firing, doing activities that are enjoyable and somewhat challenging are good for you. We don’t have all of the evidence yet to show what particular activity or how long we do that, but actually Dr. Kim Miller within RAP is very active in that field.

And so we are studying that. So I wouldn’t say stop doing it. Although of course, don’t do those games on your phone if you’re driving, we don’t wanna see those things. [audience laughing]

– Laurel: So this question actually scares me. What is the correlation of caffeine intake and Alzheimer’s? Because I drink a lot of coffee.

– Cynthia: Thankfully, there is no evidence that caffeine is bad for our brain, so woo-hoo! [all chuckling]

– Could someone explain type 3 Alzheimer’s? Is that a specific thing, type 3 Alzheimer’s?

– Sterling: They were probably referring to type 3 diabetes, which is about how the brain utilizes glucose. Diabetes is about how your organs utilize glucose. Our brains live on glucose. So 20%, 20 to 25% of the overall energy that you take into your body is used by your brain. And it’s thought that when neurons, these nerve cells that give rise to our cognition and memory, when they don’t utilize glucose as effectively, it’s thought to to be the so-called type 3.

So yes, Alzheimer’s has been called type 3 diabetes. And there definitely is a component of Alzheimer’s about energy consumption, glucose consumption, and the function of the energy units, the batteries inside of ourselves called the mitochondria. We don’t know, there’s nothing conclusive about this and we’re, it’s an active area of study in many centers around the country.

– Sanjay: I just wanted to add what Dr. Johnson said. In addition to diabetes, one of the diseases very common in the U. S. is metabolic syndrome. Have you heard of metabolic syndrome? This is a combination of diabetes, high blood pressure, and some cholesterol low, when the HDL, which the good cholesterol, is low. So it’s a combination of those diseases that increase the risk for Alzheimer’s disease.

And they all come within the type 3 classification, but those diseases or metabolic syndrome, once again, the effective treatments for various diseases that are components of the metabolic syndrome, and exercise and healthy lifestyle plays a major role in controlling metabolic syndrome. So these metabolic diseases do play a major role in Alzheimer’s disease. So I think that’s what is type 3.

– Laurel: Can concussions at a young age contribute to the onset of Alzheimer’s disease?

– Cynthia: I think they’re handing it to me ’cause I’m a mom of a soccer player, so who does a lot of headers. So there is a condition that’s called chronic traumatic encephalopathy that you may have heard of in the news that’s getting a lot of headlines for NFL players who have repeated head trauma. There’s more research is starting to be done on what we call, like smaller concussive injuries. So things like high school students, playing football or soccer student– or soccer players doing headers, other types of small, repetitive head injuries. We don’t know yet. We know that if somebody had a prior significant head injury where they lost consciousness for a significant period of time, that seems to increase a person’s risk for developing Alzheimer’s disease pathology. But there’s still a lot of things we don’t fully understand.

Is it two different processes going on? Is it one that’s kinda triggering the other to start up? So there’s a lot of research that’s being done along these lines, but overall, there’s a lot more emphasis in high schools and colleges and in the NFL too, on protecting your brain, brain health, so use of helmets for cycling, things like that.

– Where are we in terms of blood tests for a diagnosis of Alzheimer’s?

– Sanjay: There we go. So the blood-based tests, it’s a very active and a very exciting field of Alzheimer’s research. And our center is involved in this area of research. and Dr. Carlsson and Dr. Johnson is very closely involved as well. So there is increasing evidence that there are certain proteins, you heard of amyloid protein and the tau protein that Dr. Johnson showed in the brain scan. You can have amyloid PET brain scan and tau Pet brain scan and detect those proteins.

But those proteins can be also detected in blood now. And through very specialized, sensitive tests we can detect them, and there’s some evidence coming in that a ratio of certain protein we call amyloid 40 and 42 ratio in the blood may be a marker of the risk of getting Alzheimer’s disease. And that may have a direct relationship with deposition of protein in the brain. Now, this is an evolving area of research. No blood test is approved right now for diagnosis of Alzheimer’s disease, but there is a very good chance that in the near future, there may be some blood-based tests that may predict, to some degree, the risk of getting Alzheimer’s disease. Whether it will diagnose Alzheimer’s remains to be seen, but certainly risk prediction could be done through blood tests. It’s still not definite, so we are waiting for the results.

– Laurel: Several people wanna know if, they’re asking like 100 years ago, was this disease this prevalent? Meaning is the incidence increasing? I think I saw something about that in one of the talks.

– Sterling: The, that’s a great question. One thing is that we’re living longer, and so the incidence is increasing because of that. And I think that’s probably the main thing. Alzheimer’s has been around for a long time. It’s just that it’s an age-related disease. And I think that’s why we’re seeing more of it. The other thing, the other reason is that we now realize, as a society and as physicians and healthcare workers, that so-called hardening of the arteries or senile or senility is not part of normal aging. It’s abnormal aging. And now we have a more accurate label for it. Alzheimer’s is one of those labels. These other diseases that Dr. Chin mentioned, vascular disease, these are all things that are abnormal, they’re not normal aging.

– A number folks wanna know about the impact of alcohol consumption.

– Nathaniel: I feel like I’m getting all the hard questions here. [audience laughing] Well, there’s a– it depends on the outcome that you’re looking at. So I have this conversation in clinic a lot. There’s a lot of research out there showing that people who are healthy, that when they have a certain mild to moderate amount of alcohol, that it reduces one’s risk for cardiovascular disease. And that seems to be pretty solid. Now, the Europeans are recently coming out with research saying that any amount of alcohol increases one’s risk of cancer. And so they’re starting to argue something slightly different. In the realm of dementia and Alzheimer’s disease, it’s similar to the cardiovascular; there’s some belief that a mild to moderate amount can have a neutral or protective effect on cognition. Now, I’m someone who will have alcohol at times, but I still don’t advocate for that.

Only that when I think about the process of alcohol, it’s a depressant, it suppresses our activity in our brain. So I think that if a person enjoys alcohol periodically and not a lot every day, that that would be reasonable. But I just wanna caution people that it isn’t something where if you read an article that says alcohol may reduce risk of Alzheimer’s, don’t go out and start drinking, that’s not really what they’re showing. [audience chuckling]

– Laurel: That’s good, that’s good. Can heart attacks exacerbate risk of Alzheimer’s disease?

– Cynthia: So with a heart attack, sometimes people will have low blood flow to their brain during that event. So if somebody’s heart stops or they have a heart attack where their heart is not pumping as well, that means the blood flow to the brain is reduced. So that single event can cause, can exacerbate the memory changes or the thinking changes. Just like there’s some other surgeries and some other conditions that if somebody’s got reduced blood flow to their brain, blockages in the arteries to their neck, those things together can cause reduced blood flow to the brain and contribute to cognitive decline. Whether it’s actually triggering those plaques and tangles to get worse, that’s not clear yet. But it does seem like there’s a link between the low blood flow to the brain and the plaques and tangles.

But usually when someone has a kind of a quick decline after a heart attack, it’s usually from that low blood flow to the brain and that part of the brain not getting nourished enough during that period of time and taking a while to come back from that.

– Does mild cognitive impairment always progress to dementia?

– Sanjay: An important question, and there is evidence that people who are diagnosed with mild cognitive impairment or MCI, every year, about 12 to 15% of people with a diagnosis of MCI will progress to Alzheimer’s disease. So there’s clearly evidence that if someone is diagnosed with MCI, their risk of progressing to Alzheimer’s disease is higher. In fact, some people in the field argue that MCI is really the very early stage of Alzheimer’s disease. Now, there is some evidence that about one in five people or 15 to 20% of people with a diagnosis of MCI may revert back to normal. Now, of course, data does suggest that, that means that perhaps when they were diagnosed with MCI, on that day, their memory testing for whatever reason, just met a certain cut point and they were diagnosed as MCI. So there’s no magic brain scan or a blood test to diagnose MCI, it is dominantly driven by your memory test result, and the fact whether you’re leading a normal life. So there’s some evidence that one in five people may, on repeat testing, go back to normal. But if someone is diagnosed with MCI, the risk of progression to Alzheimer’s does increase.

– What actually happens when someone dies of Alzheimer’s disease, which systems fail?

– Andrea: So as Dr. Johnson mentioned, Alzheimer’s disease is a disease that takes place predominantly in people who are older. Who very often have other chronic conditions. So many people living with Alzheimer’s and dementia may die from those conditions. One of the most common causes of death in Alzheimer’s and other dementias is actually pneumonia. We have very complicated musculature that helps us swallow. And what happens is, we lose that ability to do that, and food and other liquid enters into our breathing tubes, and we get an infection from that. So that is one of the most common causes of death. But in the end, again, the cases of individuals who are older and there are often other things going on.

– Rebecca: Could the greatly increased use of pesticides and herbicides over the past 30 years underlie the rising rate of Alzheimer’s?

– Sanjay: This is for Dr. Chin. [audience laughing]

– I think that’s an excellent question. And I do know some of our colleagues in Chicago at the research over there, they are looking at environmental toxins, sound pollution, things like that. It’s always possible, we do not have the evidence to show that, but in a place like Madison, where we have farmers’ markets throughout Wisconsin, I think it does speak that there is this movement of wanting to know your farmer, wanting to know what’s being put on the food. There’s clearly something to it. But no, we don’t have any evidence to say that pesticides and insecticides are a direct contributor. They’re clearly not good for us, but we can’t say anything more than that.

– If a patient is in the later stages of Alzheimer’s, is there really any benefit to continue with Aricept and Namenda? Patient is now in a memory care facility.

– Cynthia: So these are always individual decisions on when to stop some of these therapies for dementia treatment. Usually what I’ll tell families is if the person still has some ability to engage in their self-cares or to engage with a family, they may wanna consider leaving one of the agents on, but if somebody is really in a memory care unit, they’re getting the cares that they need by other people. A lot of times we’ll simplify the medication list and really think, what is the benefit of this medicine versus the additional potential side effects and the burden and the cost of taking these medicines? So a lot of times if somebody is in a memory care unit, we may gradually taper them off of the medications.

– This is a great final question about funding for research. It says, if money was no object, could Alzheimer’s be cured within a period of 5 years, 10 years? Shouldn’t there be a collective will and moral imperative to fully fund the necessary research?

– Sanjay: What an important question. And let me start by saying that there are no shortcuts to research. In other words, every disease that we have been able to control and find an effective treatment, think of heart disease, cancer, diabetes, high blood pressure, it is the result of research, that we were able to develop new treatments and control the disease. So really none of those diseases are cured, but they become chronic, well-controlled diseases, and you have a normal, healthy life. In terms of Alzheimer’s disease, I think the same applies. It is critical for us to continue to have increased funding. Just few years ago, the National Institutes of Health was only putting in $600 million per year to support Alzheimer’s research, compared to $6 billion for cancer and $4 billion for heart disease. It is in the last two or three years, that with public advocacy, pressure on the Congress, that there’s increasing research funding for Alzheimer’s research. And right now, it’s about $2.8 billion a year from the federal government and other sources. Now, that has made significant advancement at the pace of research in Alzheimer’s disease. So the answer is that we certainly need more and more funds so that we can launch some high-risk studies that we were not able to do before. High risk can give you high returns, and one day, one of those studies will give us a breakthrough in the treatments.

So the answer is absolutely yes, increased funding is critical. And I just want to make one final comment that every dollar we get from the federal government, we as scientists have to raise another 42 cents to complete our study. And I think that is where philanthropy and fundraising comes in. Because the government never gives us all the money we need. They expect us as a community and institution to raise about 40% of the fund we need to complete a study. And I think this is such a critical– and we’re so grateful for you to be present and support this very important cause.

But money is important, we still need more funds, and it has to come from multiple sources, not just the government sources.

– Well, I think that’s a great thing to wrap up on. Thank you. [audience applauding]